37: Shoulder Pain, Impingement, & Rotator Cuff Issues: The Most Common of Problems
Episode Transcript
Summary: Til Luchau and Whitney Lowe share their ideas, strategies, techniques, and tests for better results with the most common type of shoulder condition, subacromial pain syndrome (SAPS) and its myriad presentations, including rotator cuff pain, etc. Download the handout with detailed episode notes, techniques and tests from http://a-t.tv/ttp-saps/
Episode topics include:
- Shoulder Impingement Syndrome: SIS or SAPS?
- Rotator cuff syndrome, labrum injuries, adhesive capsulitis, and more
- Biomechanical and biopsychosocial perspectives and approaches
Get the handout or get the full transcript atTil orWhitney’s sites!
Resources and references discussed in this episode:
- Download the handout for full references and more
- Whitney Lowe’s site: AcademyOfClinicalMassage.com
- Til Luchau’s site: Advanced-Trainings.com
Til Luchau:
Til Luchau here. Books of Discovery has been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, e-textbooks, and digital resources. In these trying times, this beloved publisher is dedicated to helping educators with online friendly digital resources that make instruction easier and more effective in the classroom or virtually.
Whitney Lowe:
I’m Whitney Lowe. Books of Discovery likes to say learning adventures start here. They see that same spirit here on The Thinking Practitioner Podcast, and they’re proud to support our work, knowing we share the mission to bring the massage and bodywork community enlivening content that advances our profession. Check out their collection of e-textbooks and digital learning resources for pathology, kinesiology, anatomy and physiology at booksofdiscovery.com, where Thinking Practitioner listeners can also save 15% by entering thinking at checkout. Thanks, again, so much to Andrew Beal and to the Books of Discovery team for their support of our podcast. Alright. Mr. Til, good to see you again and be back with you again this week.
Til Luchau:
Likewise, Mr. Whitney.
Whitney Lowe:
Yup, you’ve been out in the desert for a while. It sounds like you were touring around a little bit there, taking some fresh air and …
Til Luchau:
Took a trip. That’s right, headed out to Canyonlands, and we’re doing some backpacking and some camping out under the stars. Really great. How about yourself, how you’ve been doing?
Whitney Lowe:
Doing good. Trying to get a bunch of work done for me. This is the calm before the storm hits with baby bird season with us doing a lot of rehab here that keeps my wife very busy and me helping out in the springtime in early summer. This is a time where we try to get a bunch of stuff done and get prepared for that. Nice to …
Til Luchau:
You’re getting ready for that important thing you do to help spring happen. You’re helping the birds …
Whitney Lowe:
That’s right.
Til Luchau:
… be part of that whole scene.
Whitney Lowe:
That’s right. Yes, indeed. Consequently, we start thinking about things when we’re out in these spaces. Today, we’re going to think about some things shoulder related, I think. Ain’t that what we’re talking about here today?
Til Luchau:
Yes, shoulder related, shoulder pain, subacromial pain, rotator cuff pain crossover there, also known as shoulder impingement syndrome. Like I said, that crossover thing, I’m excited about it because it’s so common, but it’s also pretty broad. We’ll get into that, I think, as we go, about how that broadness is part of the story. We’re talking about shoulder pain.
Whitney Lowe:
Excellent. I think we got a whole lot of stuff we’re going to dive into here today, which means lots more resources to look into. I think we will have a handout on this episode as well to explore some of the stuff in greater detail, right?
Til Luchau:
That’s right. You can go to either of our websites and request the free handout, just click the link there in the show notes. Then I also want to give a plug for Diane Mackowski’s shoulder jam event coming up in May. If you’re listening to this live, check that out. We’ll put links to her event on our site as well. You and I are both doing that with her. Whitney, this is a fun preview conversation.
Whitney Lowe:
Yeah, it’s going to be a fun event. I’m looking forward to hearing and exploring and seeing a lot of other perspectives about various aspects of shoulder things from folks from all around the world participating in that and getting some really good input on those things. It’s going to be fun.
Til Luchau:
Yes. I mean, part of the reason I think she picked that topic and part of the reason we’re talking about this is because it is so common. There’s so much interest in shoulder pain amongst manual therapy practitioners, massage therapists, bodyworkers. In my own training, school, we have a whole lot of topics we teach. The shoulder topics are always some of the most popular if you just go down the list and see which ones are getting the clicks, which search results or landing activity. If there were shoulders in there, it gets attention. It always tells me that a lot of bodyworkers are wondering, how do you deal with shoulder issues? You see that too?
Whitney Lowe:
Yes, indeed. Tell me, Til, for those trivia nerds, how common is shoulder pain, so common pain …
Til Luchau:
Shoulder pain. Well, how common is shoulder pain? It’s super common. Subacromial pain, in particular, which we’re going to try to focus on today, subacromial pain is the most common type. They say that’s something between 44%and 65% of all shoulder pain complaints. Shoulder pain is super common. This particular type of shoulder pain is really common too. The subacromial, say, probably the most common type of shoulder pain. Then I also just want to … As we’re giving the context here, just say that it’s a big deal when your shoulder hurts. It disrupts your sleep.
Til Luchau:
It’s hard to get comfortable, which has all sorts of effects that cascade into maybe the pain perpetuating, but then also being in a bad mood, and is not feeling great. Then it impacts your function, not able to do things. You can actually have measurable weakness, of course, but then also, you just avoid doing stuff when your shoulder hurts. This is a high impact area.
Whitney Lowe:
Yeah. Shoulder being the joint of our body with the greatest range of motion and involved in so many different things. I noticed this was interesting. I’ve noticed for myself, because I’ve got a little minor subacromial pain thing going on in my shoulder, which, over the last several months, I was doing a whole lot of work emptying my father’s house, was moving a lot of furniture, moving a lot of heavy stuff. I think it’s probably a lot of what led to it. I know a lot about shoulder stuff. I’ve dealt with it for years.
Whitney Lowe:
Then still, even with all of that, I noticed this, I reach overhead, there’s that pain like, uh-oh, I’m going to be in trouble, because I feel that subacromial pain thing. That starts all this whole cascade of things running around about what’s possibly going on there. What’s probably wrong, what do I need to do about it, all that sort of thing.
Til Luchau:
Okay. You’re referring to a bunch of interesting stuff there. The activity did, of cleaning out your dad’s house, and then the sensitivity in a particular motion, raising your arm, you set up overhead. Then you said that cascade of associations or fears or assumptions that that triggers in a way. I think all those things are part of the puzzle, whatever it is that we do that aggravates it, the actual movements that seemed to trigger it, and then the way that we react to that [crosstalk 00:06:47].
Whitney Lowe:
Exactly. I think those are the kinds of things, a number of those factors that we want to pay attention to as we’re talking with our clients and taking histories of what’s going on, just to remember. Things are oftentimes not just one simple little thing, but there’s often a number of different factors that are going to be going to be a part of that.
Til Luchau:
Yup. Well, let’s narrow it down a little bit. Let’s start with subacromial impingement syndrome or SIS. There’s a lot of debate around that term, and we’ll get into that. First, let’s start there and define that. That was … Okay if I jump in on that, Whitney?
Whitney Lowe:
Yeah, absolutely. Why don’t we even start with the words subacromial and zero in on where we are and what does that mean. Let’s jump in. Tell me what you got there.
Til Luchau:
Well, subacromial, let’s talk about what that is in a second. It’s basically pain on the front or side of your shoulder when you lift your arm, either out to the side or in front of the shoulder, abduction, or flexion, or sometimes a little rotation, but basically pain on the front or side of your shoulder. This impingement syndrome was a term that was first used by Neer in ’72. That became the dominant explanation for why a lot of people’s shoulders hurt with that particular motion. The idea being that there was some sort of impingement or compression of the structures in that subacromial space, that’s the space between the acromial arch and the humeral head, and that compression would lead to tissue damage or degeneration and that would cause the pain.
Whitney Lowe:
Yeah. Let me also jump in here just for a moment to do a little brief anatomy refresher and talk about what are some of those tissues that might be impinged. Because a lot of times, there’s an emphasis, just in terms of broad generalizations, people say, oh, I got bursitis in my shoulder or something like that. Because there is a bursa there, that bursa is richly innervated. That can often be painful. We have a number of different tissues that might be susceptible to the potential compression and impingement in that area, such as the subacromial bursa.
Whitney Lowe:
We have the supraspinatus tendon in there. We have the upper margin of the glenohumeral joint capsule. We have the tendon from the long head of the biceps brachii that’s potential subjected to compression in that region. We’ll talk a little bit more in a few moments, too, about some other structures, even things that you might not think about as much like the upper more superior margins of the subscapularis tendon can get compressed, especially during some of the forward flexion motions in there. Keeping in mind, too, that the joint capsule, the glenohumeral joint capsule is richly innervated. Irritation of that capsule itself potentially getting impinged there.
Til Luchau:
You’ve named a bunch of structures, but let’s zoom out a little bit. I’m skipping ahead a little bit on your outline, but you get this sense of this is in the shoulder. Most of you know what these structures are, but let’s just get really specific. Where is that acromion, Whitney?
Whitney Lowe:
If you just put your fingers on the lateral part of your shoulder, that stiff, flat table that you feel on the lateral edge of your shoulder complex is the flat surface of the acromion process. We’re talking about the things that are right underneath that. You can feel that sharp shoulder edge there. That is your acromion process. Then just if you roll over toward the front side a little bit anterior, you may be able to feel also another bony projection …
Til Luchau:
Bony.
Whitney Lowe:
… like a little pinky finger size taking forward, and that’s the coracoid process, and then …
Til Luchau:
Now you’re not talking about my arm bone, you’re not talking about my humerus, you are medial to that. If …
Whitney Lowe:
Right. We’re on the front side of the shoulder here.
Til Luchau:
Front side of the shoulder, not the little side. You have that coracoid process sticking through from the scapula.
Whitney Lowe:
Exactly. The coracoid process and the acromion process are both structures of the same bone, which is interesting. There is projections of the scapula. There’s a ligament that spans between those two projections. That is the coracoacromial ligament. I’ve always found this anatomically interesting because we generally think of ligaments as structures that are maintaining stability between adjacent bones. Here you have …
Til Luchau:
Right, across the joint.
Whitney Lowe:
… a ligament spanning between two structures that are part of the same bone that never move away from each other. Why do you need a ligament there?
Til Luchau:
Why do you need a ligament that doesn’t cross a bony joint?
Whitney Lowe:
Yeah.
Til Luchau:
Tell us.
Whitney Lowe:
Well, I don’t have the actual answer …
Til Luchau:
I’m sorry.
Whitney Lowe:
… because I have not been able to ask the builder, but I have a theory.
Til Luchau:
Okay. What’s your theory?
Whitney Lowe:
Predominantly, the purpose of that coracoacromial ligament is to offset the potential damage to the coracoid ligament, because … Excuse me, the coracoid process, because there are three strong muscles attached to the underside of the coracoid process all pulling it in a downward direction. There’s the short head of the biceps brachii, the coracobrachialis, and pectoralis minor.
Til Luchau:
Love it.
Whitney Lowe:
They’re all pulling that coracoid process down and …
Til Luchau:
That’s true.
Whitney Lowe:
… generating sufficient force could potentially break it off.
Til Luchau:
Or at least, yeah, I could totally get that. I mean, that little thing is skinnier than your little finger. It’s a big bony projection, and there’s a lot of force on it, so probably needs some supporting structures there.
Whitney Lowe:
Go up above it, tether it, hold onto it, rope it with the coracoacromial ligament, hold it in position there.
Til Luchau:
I like it.
Whitney Lowe:
That’s my theory.
Til Luchau:
Now that we know what we’re talking about, I’ll just go back to what you’re saying. Any of those structures in there could be, say, the irritated structures, you said impinged structures, but we’re going to get into the debate around that, whether there is actual impingement or not. Any of those structures, and you’ve also used the term non-susceptive driver, this thing, the anatomical thing that seems to be the origin of the non-susceptive signal, any of the structures around there, including the acromioclavicular joint.
Til Luchau:
Because sometimes a fall on the shoulder, something like that into that joint and the irritation that comes can be much very some of those pain. Classically, the impingement syndrome is thought to be non-traumatic, in most cases. This comes up from on its own and maybe from you, maybe from cleaning out your dad’s house. It’s not thought to be a traumatic injury. There’s so much crossover between all these different shoulder symptoms that we’re taking the big picture view here.
Whitney Lowe:
Yeah. We’ll dive into some of the other mechanics and problems here. After we go through some of these terms, you’ve mentioned this discussion of impingement, I want to bring up another distinction too as they were looking the terminology that’s been used over years since Neer first explained this. There’s oftentimes a distinction made between primary and secondary impingement, primary impingement being a potential compression of those structures based on the architecture of the shoulder.
Whitney Lowe:
Meaning that maybe you have a small subacromial space or you have, for example, something that we see frequently in people over time developing osteophyte buildup on the underside of the acromion, causing the acromion to change its shape. You see references to what’s called a hooked acromion, where the acromion comes … You decrease space underneath it between that and the humeral head. That would be a primary impingement, because it’s a structural problem.
Whitney Lowe:
The secondary impingement being some type of potential compressive damage in there that’s due to usually faulty biomechanics or something in the way you’re using their shoulder, which may not necessarily be directly related to the structure of the area, but more about the fact that you’re doing something over and over again that’s causing those tissues to get irritated in there.
Til Luchau:
Irritation is secondary to an activity or impingement secondary activity, is opposed to being primarily due to those structure involved. That’s a classic distinction there.
Whitney Lowe:
Yeah. Another interesting thing that I was coming across when I was doing some reading on this recently is, in some of the discussions about this, is distinctions between what they were calling intrinsic factors and extrinsic factors of rotator cuff damage, mainly talking about supraspinatus. Because the supraspinatus is one of the most commonly involved tissues in this area, because its tendon is very vulnerable underneath the acromion process.
Whitney Lowe:
Extrinsic factors, being those external compression and pressure against bony structures nearby, like the acromion process or osteophytes on the underside of it. Intrinsic factors, being some of the things that might occur with overall tendon degeneration within itself that lead to weakness in the tendon, possibly the development of tears within the supraspinatus tendon that may not necessarily be caused by something scraping on it or pinching it from outside the tendon, but more just like overall tendinitis in other places, just as some degree of tendon degeneration occurring in there.
Til Luchau:
Well, we could branch off into all sorts of discussion about degeneration point of view, inflammation points of view, and then how sensitivity can arise from that. Or it might even be independent of that. You’re doing is you’re giving us a great outline of the way that the shoulder impingement has been classified, both in terms of types, which is based on the degree of mechanical damage and on the internal, external, and then also on the location of impingement, which is the intrinsic, extrinsic kind of thing.
Whitney Lowe:
Yeah, yeah. Those are important classifications. I also wanted to bring up one more division or classification of these types of problems. Most of the discussions that you’ll see in the literature around shoulder impingement syndrome, rotator cuff pathology, and that sort of thing focuses on what’s called subacromial impingement, which is an impingement underneath the acromion process. As we talked about a moment ago, we have that coracoid process also.
Whitney Lowe:
Then the ligament that spans between those two and the coracoid process, the ligament, and the acromion process, all together, make up a combined, let’s call it a structure that we refer to as the coracoacromial arch. All three of those things together make up the arch. Sometimes the impingement is farther toward the coracoid process and felt more on the front side of the shoulder as opposed to the lateral side. In that instance, it’s referred to frequently as subcoracoid impingement instead of subacromial impingement. This tends to affect more of the subscapularis tendon and the biceps long head tendon underneath the coracoid process, in the coracoid, subcoracoid region.
Til Luchau:
Okay, so we’ve gotten pretty granular there. We’ve gotten a lot of variations. We’ve gotten some specific locations. Is it time to talk about the debate yet?
Whitney Lowe:
Yeah, let’s talk about the debate. What is that debate?
Til Luchau:
Okay. The debate is, is there … There’s a couple. One is around the mechanism involved, and the other is around the way we describe it, the way we talk about it. The debates have been pretty large and pretty vocal. They seem to be maybe settling out. It’s been going for about a decade, there’s about four decades ago that Neer came with this classification system. The last decade, people have been saying, well, wait a minute, maybe there’s not always impingement. Impingement syndrome assumes that there’s some mechanical impingement.
Til Luchau:
Maybe there’s pain or symptoms that are independent of any impingement. For evidence of that, almost everybody narrows that space and normal motions and the measurements that are given, that space narrows all the way down to two millimeters in people without any symptoms at all, and opens up as much as 17 millimeters. That’s just part of normal function. There’s a compressing of that subacromial space and all those structures that run through there, just the normal motion without any symptoms at all.
Til Luchau:
Then the correlation between shapes and symptoms hasn’t borne out in the research. It turns out there isn’t a correlation between acromial architecture and particular symptoms. You can’t reverse engineer and say if you have this architecture, you’re more likely to have a symptom, it turns out. Now, that’s not to say that’s not always involved. There can be a compression involved. Most people, I think, at least from my reading and my listening, Rachel Chester, about her research she’s done, but also in the podcast with Physio Edge, we’ll put a … I’m saying that wrong, was it … You know which one I’m talking about, Whitney?
Whitney Lowe:
It is Physio Edge Relief, was the one.
Til Luchau:
I think Physio Matters. I think I gave their competitor a plug. Physio Matters, I believe.
Whitney Lowe:
[crosstalk 00:20:18]
Til Luchau:
We’ll put the right link in the show notes.
Whitney Lowe:
They’re both good, so listen to them both.
Til Luchau:
They’re both good, there you go. In fact, she’s saying it’s formally called the subacromial impingement syndrome. Since this suggests that what’s needed is more space and we now know that acromial shape is not associated with pain, she’s preferring, as I think most people, the term subacromial … Help me out here, I lost …
Whitney Lowe:
Pain syndrome.
Til Luchau:
Thank you. Subacromial pain syndrome, rather than impingement syndrome. This is describing the symptom rather than the presumed mechanism. We’re not sure of the mechanism. She’s saying, let’s describe the symptom. What do you think of that?
Whitney Lowe:
I think that’s an important distinction, because describing it as an impingement syndrome immediately brings our focus into how do we make more space in there, so that it doesn’t get pinched. We will tap into this a little bit when we talk about the treatment. One of the things that’s led to this reexamination of this whole idea of subacromial impingement syndrome is some of the treatment processes that have been used to address this, such as surgical decompression and making more space in there and acromioplasty and things like that, that have done specific things to make more space, have found some of the surgeries work really well.
Whitney Lowe:
In a number of those instances, they get just as good of effects with various other types of procedures. In fact, they’ve done a number of sham surgeries where they didn’t actually do the subacromial decompression, but they just did an arthroscopic incision. People got better. Their pain decreased, even though nothing was actually done in there. It really changed the perspective [inaudible 00:22:01] …
Til Luchau:
Nothing structural, yeah. That’s why …
Whitney Lowe:
… on how much is structure really the cause of this. I think that’s …
Til Luchau:
That’s the bait. That’s huge. That’s huge for me, because my training as a rolfer and structural integrator, and then the training that I gave to people said, let’s create space there, if there’s shoulder pain. Even adhesive capsulitis or even something like a rotator cuff irritation, any of those things we can “now create space,” and that seems to relieve symptoms. That was presuming that compression was the problem. Well, when I read and hear this stuff, I go, well, of course, we don’t know that compression is the problem. We know that sensitivity and pain are the problems. There’s probably ways we can work with those very directly. That might involve decompression, but maybe not. Maybe it doesn’t have to.
Whitney Lowe:
Yeah, yeah. Because another thing that was interesting that I ran across this and looking at it, again, some of the systematic reviews of these different treatment procedures is that even in a number of the individuals who had failed rotator cuff repairs …
Til Luchau:
[crosstalk 00:23:05]
Whitney Lowe:
… so for example, they had a rotator cuff surgery and the surgery was performed. Then for some reason rather, it failed. They went back and looked at the rotator cuff with MRI, they saw severe significant tears still there, but the person was out of pain. Why does that happen? That just like …
Til Luchau:
That’s right. The other side of that was just looking at the incidence of rotator cuff tears, it’s so common, just the number of pops. One-third of people have some sort of tear damage visible over a certain age visible on a scan, and they don’t have symptoms. The correlation there between rotator cuff image findings and symptoms is pretty poor as well.
Whitney Lowe:
Yeah, yeah. That leads us to then thinking about, alright, then, well, what is it? Because, obviously, something’s going on there. Some of the theories now that have emerged that are suggesting that what we’re probably looking at is a complex of factors in many people that might be mechanical factors. Because, clearly, I think there is a role for the mechanical idea of impingement being a driver of pain sensations in there. That certainly makes sense.
Til Luchau:
Yeah, would you … Sorry. I’m going to interrupt. Because you say that is the qualifier on some people okay to edit?
Whitney Lowe:
Yeah, yeah.
Til Luchau:
Okay. Because that’s how I think about it, too. I think there’s also people [crosstalk 00:24:28].
Whitney Lowe:
I think for certain people, that’s a factor. In other people, it may not be the major factor. What is it in number of those other people. There have been alternating theories proposed. One of them is related to what we’re probably seeing in many of these complaints is, and we can see why it’s easy to blame the mechanical factors of potential impingement and compression here because there’s not many places in the body where we see this same kind of scenario where soft tissues get pinched between two bony structures. This is a place where you get pain.
Whitney Lowe:
You see the potential for that pinching between two bony structures, and then you jump to the conclusion, alright, the pinching of the soft tissues is the cause of pain. We have tendon disorders and tendon pain all over the body …
Til Luchau:
Achilles tendon.
Whitney Lowe:
… in places where we don’t see that. What was that?
Til Luchau:
I’m thinking Achilles tendon. There’s not a lot of structures there that pinch it, but we get the same kind of tendinopathies and tendon irritation there.
Whitney Lowe:
Exactly. Patellar tendon, like extensor tendons at the wrist and forearm, all those kinds of places. Why not? Is this potentially an issue here that you have the same kind of metabolic or possibly, in many instances, age-related degenerative processes in the tendon that might cause those kinds of pain sensations? Because we see a lot of subacromial pain in older populations.
Til Luchau:
Yup, six decade of life, they say, which makes our 50s … Sorry, Whitney.
Whitney Lowe:
Hey.
Til Luchau:
I’m getting past that.
Whitney Lowe:
You are. I’m rapidly crashing out of my 50s as well this year. I’m making the best of the last six months of my 50s I got left here.
Til Luchau:
Good. Enjoy it.
Whitney Lowe:
Yeah. Where were we? Talking about metabolic factors and things that might be related to tendon degeneration, maybe related to some of the pain sensations for a lot of these people.
Til Luchau:
Now, wait a minute. That’s, again, we’re questioning the assumption that impingement causes pain. Isn’t there some reason to question the fact that degeneration is part of the pain in tendons as well? Do you know what I’m saying?
Whitney Lowe:
Well, why would we … If we’re saying it’s possible that all these things could be present in different degrees for different individuals? I’m not sure I’m getting what your question is there.
Til Luchau:
My question is, you said tendon degeneration, age-related tendon degeneration, et cetera. There can be age-related tendon sensitivity without degeneration.
Whitney Lowe:
Yeah, sure.
Til Luchau:
They can be painful, irritated, and inflamed even tissues without degeneration. This goes back to the tendinitis, tendinosis to me [inaudible 00:27:20], which, again, that pendulum has swung back and forth. We used to think it was all inflammatory than we thought none of it was. Now we’re realizing that there’s probably both involved. It’s less clear sometimes what the primary generator is. Both of those are routes to help make it better if they’re working with …
Whitney Lowe:
Yeah, I think so.
Til Luchau:
… the metabolic questions you mentioned, like the inflammation ones or the perhaps degeneration or healing questions there as well, or mechanical loading.
Whitney Lowe:
I love going back to, and maybe with something that we can make a link to on our visual handout or something like that. Greg Lehman’s concept of the painful cup, he talks frequently about each individual comes to us with a cup. It might be comprising a unique group of factors that maybe pain irritants or aggravators and some of those may be metabolic factors. Some of those may be mechanical factors. Some of them maybe overuse. Some of them maybe all kinds of things stress related, whatever. Each individual brings a unique cup of those things to us.
Whitney Lowe:
It’s important for us to consider what are all those factors that might potentially be involved as we try to evaluate the nature of that problem in order to construct a treatment strategy that we think [crosstalk 00:28:38].
Til Luchau:
I know the visual you’re talking about, and it’s also used for stress. Greg uses that. I think I forget who he attributed to, but it’s the idea that anything in that cup can raise the water level of it. When it spills out, we have pain or we have an episode or we have a flare up or we have something like that. You’re saying that maybe degeneration could be in that cup, maybe metabolic inflammation could be in that cup, and maybe activities could be in that cup. Lack of sleep could be in that cup, et cetera.
Whitney Lowe:
Yeah, exactly. All those things, I think, potentially involved there. Looking down here, you’ve got a couple other things that I want to look as we talk about subacromial pain syndrome. There’s some other things we’ve talked about tendon disorders in particular, but you’ve got some other things you’ve mentioned here that we need to consider as possible causes and some other things to consider like …
Til Luchau:
What are you looking at [crosstalk 00:29:33] back on track, like …
Whitney Lowe:
Yeah. You mentioned subacromial bursitis and calcific tendinitis and rotator cuff pathologies and things like that. These are all some things that might be part of this whole bigger picture of subacromial pain syndrome.
Til Luchau:
Well, yeah. That’s part of the debate around calling impingement, that there could be lots of things going on there that could cause that sensitivity or pain. That’s why somebody like Derek is saying, 2014, he’s saying it’s all non-traumatic, usually unilateral shoulder problems that cause pain or involve pain, that they’re localized around the acromion and they often get worse during or after lifting your arm or sometimes rotating the arm. That says SAPS, subacromial pain syndrome definition.
Til Luchau:
Those things you mentioned, the bursitis, the tendinitis, tendinopathies, rotator cuff could all be part of it, as we said. Now there’s, like we said, we’ve been saying all along, we don’t really have a big agreement on what is causing the pain. As you said too, there’s a lot of agreement that there’s a lot of factors in that cup. How would we know what might be causing that pain? Is it time to talk about tests, you think?
Whitney Lowe:
Yeah. This is a good time to segue into, I think, looking at how do we figure out the nature of these problems. The one thing, in terms of reading a lot of literature around this, it seems evidence still is that there are no real absolute definitive ways to identify this. The best that we can often do is look at the accumulation of evidence through testing a number of different strategies and trying to keep a bigger picture view about what may be potentially going on here.
Whitney Lowe:
One of the things that I always emphasize greatly and would start with is, is just the critical importance of a thorough and comprehensive history. Because this is something that I just think a lot of soft tissue practitioners don’t do thoroughly, is dig into a lot more of the questions about the nature of what causes pain, how’d it come about, the previous involvement of those areas, and really probing for a good picture of the things that potentially produce pain prior to doing our physical examination. Those are critical things that I think are necessary at the real outset. Then we maybe get into some other things that might be identifiable during the physical examination part.
Til Luchau:
You’re saying taking a good history, have a good thorough conversation with your client beforehand is crucial to your way of thinking. How do you use that information? Do you then start to form a hypothesis for yourself about the factors involved?
Whitney Lowe:
Yeah. Let me give an example of how that would drive what goes on in the physical examination. Let’s say a person is talking about certain types of things that they can’t do, like when I tried to reach up and to pull the garage door down, lift my arm in this position. You got a physical activity motion that they’ve described, is one of the most painful things they can think of, that reminds me this is what hurts every day when I do this. I’m making note of those motions and the direction and position that that shoulder is in that they say hurts a lot.
Whitney Lowe:
I’m probably going to leave that motion till the end of my evaluation process. Because if I start having them try to repeat that when I start to test range of motion and test their movements in their shoulder, if I test those most painful motions first, I’m a flare up the whole thing and make everything else hurt. Then it’s going to be harder for me to tease apart what structures might potentially be doing that. The history questions drive a lot of what we decide to go evaluate more specifically in the physical examination, maybe also the order in which we attempt to do those things, too.
Til Luchau:
You’re sorting that the cards in your hand. The hand you’ve dealt, you start sorting them out and going, okay, these are the ones I’m going to play last because they might be the irritating ones. I want to save them and don’t want to flare things up early in this process.
Whitney Lowe:
Yeah.
Til Luchau:
Okay, great. Also, I mean, I do that too. I’ll just make a statement there, rather than asking. I want to hear your thoughts about it. I do that too. I’m also asking questions like, what makes it worse, what makes it better, as clues to me of some of the possible mechanisms, or at least factors involved. I’ll ask things like, have you had, say, manual therapy, bodywork with it, did it help? Because some of these things that might involve inflammatory reaction can be worsen to aggressive approach, and I want to know if that’s happened before, so that I can modulate my ambition before having that out.
Til Luchau:
Then it might also be, if it’s an ongoing issue for someone and I suspect, I might ask something like, how is your sleep? How are your stress levels? How do you address that? What resources do you have for dealing with stress, for example? What is your level of physical activity? Because that’s been really clearly correlated with symptoms right here in this joint, someone’s overall physical activity level.
Whitney Lowe:
Yeah. Again, all of these factors of history are really crucial. Just to make another point about that, too, a lot of times what I’m doing with the history is also setting up the process for how I’m going to make comparisons when I look at patterns. For me, and this is just part of the way I think, is that I look for patterns that tend to make sense. For example, I might ask in history, if a person says like, oh man, it really hurts when I lift my hand up overhead to grab the handle on the bus when I’m on the subway or whatever.
Whitney Lowe:
Then I’ll ask them, well, does it hurt when you are lying down in bed and you just have your hand draped up in that same position? Does that hurt? Then I’ll say either yes or no to that. Now I’m making a comparison between active movement and passive positioning of the shoulder in that same position, and seeing if there’s pain with both of those things. Because one of them may indicate more of a problem with the contractile tissue, like the supraspinatus that’s engaged to lift the arm up and grab the subway handle. The other is just a positional thing. Then I’ll go through the same motion …
Til Luchau:
I want to just take out my highlighter … Sorry, I’m taking out my mental highlighter interrupting you and saying, let’s highlight that. Because you’re saying you’re trying to find out if contractile tissues involved by bringing in an active motion of that structure.
Whitney Lowe:
Right. Then we compare that with a passive motion of that structure by not engaging the contractile tissues. Then when I do my actual physical examination, I’m going to test those motions into a manual resistive test, which will engage the contractile tissues, but not put the shoulder in that position where it might further be getting compressed. Again, that helps me tease out a pattern of, is this is particularly like a supraspinatus involvement or might it be a non-contractile tissue like the bursa, the ligament, or something like that.
Whitney Lowe:
That helps tease apart what structures, I think, are most involved in that process. For me, this ability to look at these patterns of active motion, passive motion, and the resisted motions, and then compare the results from them is really helpful in trying to discriminate where I see those tissues involved. To give an example, that will include something on the handout. We’ve got these little charts that I put together that help you think about what happens to those different tissues, during those different motions when you’re doing the evaluation process.
Til Luchau:
You gave me a preview of those. Those are a great cheat sheet. You get to compare the motions with these different variations you described and get a little key under what structures might be involved.
Whitney Lowe:
Yeah, so …
Til Luchau:
Okay. Can I ask you another question about that?
Whitney Lowe:
Yeah.
Til Luchau:
Let’s say you do your comparison of active and passive. Let’s say you suspect contractile tissues, which I assume you mean myofascial structures or muscle fascial units, myofascial units called muscles.
Whitney Lowe:
Yeah, muscle tendon units, yup.
Til Luchau:
Alright, muscle tendon units. Let’s say you identify one of those, then you just, what? Then you go rub the heck out of it, now that you know what it is?
Whitney Lowe:
Maybe. I used to say that, yeah, I got to go rub the heck out because I’m going to break up the scar tissue and do all the other things that we were told that we were doing those things from the impingement process. Now I’m not so sure that those are actually the things that are happening, but lots of different strategies may be helpful in there. This also does help, I think, a lot. Because this can help a lot in patient education in terms of what we’re trying to tell our clients the things to avoid early on, the things to maybe focus on. Gradually work your way back into doing this kind of thing, but don’t start doing this kind of thing early on, because you’re going to overload that. That really irritated muscle tendon structure.
Til Luchau:
Okay. You’re using the results of this test to educate the patient and help them understand which things they want to grade or experiment with or go slowly back into.
Whitney Lowe:
Yes. Because, I mean, for me, the assessment drives the treatment. The assessment, giving us a good roadmap for where we think the primary problems are, whatever the nociceptive drivers are for that particular problem, and then how do we chart a course that’s going to be able to get them back on track and decrease any further aggravation of those involved tissues and find some results there.
Til Luchau:
Well, I was obviously joking about rub the heck out of it, but would you say that you go choose some techniques that might specifically touch or work with those structures you’ve identified? How do you approach that?
Whitney Lowe:
Yeah, absolutely. Because, again, and we’ve talked about this before, while our ideas might change about the narrative behind what we’re doing, we found treatment strategies over the years that seem to be really effective. Something like deep transverse friction of irritated structures has, for years, been shown clinically to be pretty effective in dealing with a lot of chronic overuse tendon problems. I’m using that as your rub the heck out of it model.
Til Luchau:
Okay, the most aggressive approach perhaps to really get in there and work it. If irritated, let’s go [inaudible 00:40:17]. That’s really different.
Whitney Lowe:
Yeah. Our narrative around that formerly was that we were helping to break up fibers, adhesions, and reel on scar tissue that was getting that to be working well. I’m not so convinced any longer that that’s really what’s happening for a number of biological and physiological reasons that make that less plausible to me. I know it gets good results in many instances. I still think there’s a lot of advantage to what we might be doing with descending modulation and a targeted treatment approach that gets the whole neural and metabolic processes going in there.
Whitney Lowe:
I think there’s still maybe some potential benefits of the things that we’ve seen about increasing fibroblast activity by pressure and movement on some of those structures that might have a role in the healing process, in the re-management process. I think there’s a lot of potential benefits to those things that just might be a little bit different than what we thought they were previously.
Til Luchau:
Yup. You’re just making me think. I know we’ve got into this in other episodes as well, about working with inflammation and tendinopathies and things like that. From my side, I rarely rubbed the heck out of it. Although I will sometimes think about working fairly directly in a way that I’m consciously stimulating an inflammatory response. Now, that is playing with fire, because that can flare things up. I do that really judiciously and with clients who we have both the rapport, but especially who have the resilience metabolically, medically, age wise, and things like that to deal with a flare up if we inadvertently cause one.
Whitney Lowe:
Yeah. The other thing that I would note here, too, and this is with a number of the techniques that are listed on the handout for valuable ways to address this. A lot of what we may be doing is really focusing more on normalizing scapulohumeral mechanics and just making those shoulder function better of just more balanced or more freely moving. That seems to have really helpful effects as well.
Til Luchau:
Now, I’ve changed my thinking on that. There’s a bunch of handouts in there with techniques from me. I don’t know if you’re talking about those or from the techniques … Sorry, the things you’re going to put in the handouts. I’m actually not thinking of … What am I thinking? I’ve gone away from, say, the scapular dyskinesis idea of helping the shoulder blade and shoulder move “normally.” I’m more generally thinking of adaptability.
Whitney Lowe:
Yeah. Well, and that’s …
Til Luchau:
I’m not trying to restore proper biomechanics as much and some of this, again, is Greg Lehman’s, some of it’s just the time and years of working. I’m not trying to restore proper biomechanics and more thinking about how can I help that shoulder adapt to whatever demands are being put on it. The other part of that is desensitize. How can I work with pain per se, pain itself, using my touch and maybe through those mechanisms, like you mentioned, like the descending modulation. Sometimes it’s a really gentle touch that helps you sensitize. Sometimes there’s pressure that feels really right and helps you sensitize.
Whitney Lowe:
Yeah. That is essentially what I was getting at that I think a lot of those techniques seem to be aimed more at just restoring optimum function, whatever that may necessarily be.
Til Luchau:
Can I take …
Whitney Lowe:
It doesn’t necessarily mean you’ve got X range of motion available in your shoulder, but you’re trying to get functional movement restored there.
Til Luchau:
I’m jumping all over, because I want to take the word optimal out of there. I want to say it’s restoring function, it’s restoring adaptability, much less oriented around an optimal or around an ideal or around even “normal” than I used to be and I was trained to be, and that I trained people in. Now it’s more like, can you adapt? Is there a range of options? Do you have enough of proprioceptive acuity, enough sense body awareness, or enough responsiveness to be able to respond to the demands or coordination given, to respond to the demands that life puts on you?
Whitney Lowe:
Yeah. I think that’s a really important distinction. Because for the person who wants to be an Olympic shot putter, that range of motion and generating power through a very great range of motion is really important, and for that individual that just needs to be able to get the can of beans off of the upper shelf. That’s really all the major demands there. The optimum …
Til Luchau:
It’s my highest [crosstalk 00:45:03] life is my shoulder, right?
Whitney Lowe:
Yeah. Adaptability is going to be a bit different there. Sure, yeah.
Til Luchau:
Yes. I mean, that’s also to say that there are so many factors involved in a happy shoulder. It is spine, ribcage, scapular relationships. It is the way I sit. It’s the habits I have around where my shoulders rest. I’m no longer thinking about let me reposition the shoulders back to an optimal place. I’m more thinking about, can they have a full range of options, both protraction and retraction? Can I elevate as well as depress? Then can my glenohumeral joint be comfortable and moving in all sorts of directions?
Til Luchau:
I’ll do the same things in those tests you’re describing, but I’ll look for a sensitivity. Then I’ll work with the sensitivity in whatever way seems right, either as calming it down or it’s challenging it gently or it’s helping someone have other options until it can be more comfortable.
Whitney Lowe:
Right. Excellent, yeah. I want to backtrack for just a moment. I know we’ve ventured into talking about some treatment strategy things here. There’s one more important point that I want to make about …
Til Luchau:
Please.
Whitney Lowe:
… the assessment evaluation process. Because for years, there’s a lot of emphasis placed on a number of special orthopedic tests. The empty can test, the Hawkins–Kennedy test, the Neer test is the means for identifying these particular subacromial pain complaints. Just want to emphasize that lot of the research literature that’s been looking at the evaluation process is not found many of these procedures to be highly specific and highly accurate, and really nailing down what’s happening in these areas.
Whitney Lowe:
Like many other places, I think there is a decreased emphasis on the critical importance of those testing procedures. That’s why I go back to this whole process of looking for patterns and looking for more comprehensive pictures that paint an understanding of what’s happening here in conjunction with the history to evaluate what’s going on, because too many people have jumped to simplistic kinds of evaluation recipes, just by running through a couple of these orthopedic tests. To me, that’s a real big mistake that is shown to be less accurate.
Til Luchau:
Or the opposite can be true, where it gets way more complicated. Maybe we need to make it too, that we need to do five tests and we have to do them precisely. Then the illusion comes up that we know, then we know what is involved, and then we can just do our technique, it’ll be done. Not only is it not have to be so complicated, but often, even if we do the test correctly and we get a result, it’s not always what helps us strategically in terms of helping someone resolve the situation.
Til Luchau:
I’ve moved more and more toward the actual treatment being the test, where if I can reproduce the symptom, I can find it, I can identify it, and then I can help someone adjust their relationship to it or just the way you’re moving in a moment, but also the demands they’re making on their body. I’ve done some really good work with them at that point.
Whitney Lowe:
Yeah. I want to also bring up a point here, too, about the …
Til Luchau:
Please.
Whitney Lowe:
… biopsychosocial factors that you mentioned this in relation to some of our treatment strategies. There’s also something, and I don’t hear this talked about a lot, but I do think it’s relevant, and that has to do with the biopsychosocial aspects of assessment. That when you go through, for example, this kind of evaluation as detailed evaluation process with somebody and you really take the time to explore this, I mean, I have had so many clients say to me over the years, why has nobody ever done this with me before?
Whitney Lowe:
To me, you have built a high degree of rapport with your client, that’s also established a degree of interest that you’re expressing in them and a degree of confidence in you as a practitioner that I think really spills over into how effective that treatment becomes. Because we talked about this in our episode about expectations with our bishop.
Til Luchau:
That’s right.
Whitney Lowe:
This is an example of where those kinds of ideas of expectations really play out into the treatment success, because you have really already established a strong degree of rapport and trust and confidence from your patient because you’ve gone through this detailed thorough comprehensive evaluation process with them and they think you know what you’re doing.
Til Luchau:
There you go.
Whitney Lowe:
I do think that there’s some real strong benefits there.
Til Luchau:
That also, there’s a nonverbal component of that or aspect that’s had nonverbal version of that, where if once you get someone on your table, you start working with them if they sense or feel that your hands listening to them. If your hands are discovering things about their body and showing them things about the body they weren’t aware of and in fact, I was listening to what’s going on in their body, that same kind of trust can deepen and be multiplied in a nonverbal sense as well. There’s the thorough history taking in the interview, and there’s the thorough listening that we do with our hands that also leverages that expectation effect and lots more.
Whitney Lowe:
Yeah, absolutely. Any other key components you want to bring up related to treatment oriented stuff? I know we’ve gone through a lot of stuff here.
Til Luchau:
We’ve gone through a lot. I mean, yeah, and I think probably as we’re starting to wrap up, the bigger question that we’ve gotten into a little bit is, what helps? Let’s go through it a little systematically. What can we do that really helps when we have that scapular shoulder pain we’re talking about? One of the first things I do is I make a call for myself based on what I’m hearing from the client. What is it that I want to address in my work that come in? I don’t want to just jump in assume, oh, it’s pain that we’re going to try to “fix” today.
Til Luchau:
I want to listen and say, now, how are they experiencing that disturbance? Is it pain? Or is it the stiffness? Or is it weakness? Or they give me clues that it’s about the apprehension, the guarding, the fear, the uncertainty, the worry about things coming, getting worse again? What essentially is the domain that I want my work to affect? Because so often, I see this with hands on practitioners, we get where it is and we think we know what to do. We understand where the location is, and then, yeah, I got a technique for that. Let me go do it.
Til Luchau:
The disturbance, I think, that might actually be upsetting to the client might not have an anatomical location. It might be, again, more of a apprehension or fear. There’s ways that I can slow down and listen. With both my words and with my hands that we’ve mentioned, that actually help shift that apprehension as well. Then stiffness, the distinction between stiffness and pain, your test that you’re going to put in the handout, there have some nice ways of dialing down, is it contractile or non-contractile tissue? Stiffness and pain are different.
Til Luchau:
Really, in my treatment, when I really get time to work with someone, understanding something can be sensitive without being stiff, and it can be stiff without being sensitive. Just because we make it less stiff, doesn’t mean it could have necessarily feel better. That’s one of the fundamental assumptions from decades ago in our work that is being called into question to.
Whitney Lowe:
Yeah. In an instance like that, too, the stiffness may not be the same thing as what is the pain driver.
Til Luchau:
That’s right.
Whitney Lowe:
The stiffness may be the reaction to that perception of pain or the fear of pain in that area. The muscles are guarding and limiting motion, and then that’s what’s perceived as the stiffness.
Til Luchau:
Absolutely, yeah. That’s part of why somebody who will get such dramatic results from one session too, that we can really quickly turn down someone’s guarding. Then they realize their body realizes, oh, I can do things I didn’t think I could do. All of a sudden, there’s a whole lot of range of motion that comes back. I mean, I do focus a lot on gentle mobilization. In particular, that inferior glide of the humerus, if there’s that subacromial pain, that pain in those places we’ve been describing.
Til Luchau:
My old explanation was I was decompressing that space, I was preventing so much compression. I still think that’s probably going helpful in some cases. For sure, the work I do to help make sure there’s the inferior glide capability of the humerus, and I’ll put the handout in that explains that, it seems to be really effective for this type of work.
Whitney Lowe:
Right. Some really good strategies there. We’ve uncovered some nice dilemmas to consider and think about with subacromial pain here looking at some of these causes and causative factors. Any last thoughts that you want to wrap up with there?
Til Luchau:
There are details more than summary thoughts. There’s still a couple little details I want to catch there. We’ve talked about being really tissue specific or structure specific. Often, we’ll find that anything in that region can help. It can be surprising what does. Anatomically, I’ll often think of anything that crosses the glenohumeral joint and anything that crosses the acromioclavicular joint as being a possibility. Then there’s also times, especially when something’s really painful, it’s starting somewhere completely different, gets even better results in the shoulders than starting locally.
Til Luchau:
Then the same has been true, found to be true with, say, strengthening protocols, where sometimes exercises that target the most painful structure are too hard for people to do or too painful, too challenging and irritate things, and that overall physical activity has been shown to be really helpful for a painful shoulder. It’s painful subacromial shoulder pain. Just the people that exercise, let’s say, 10 minutes a day, had far fewer severity of symptoms than the people that had no physical activity. Just a little bit of overall health camp quite a bit with so many things.
Whitney Lowe:
That really highlights, too, the factor that so much of musculoskeletal care is very mechanically driven. It’s very mechanically focused. We’ve got this problem in the shoulders, so now fix those things in the shoulder, and that’s what we need to do. In many instances, that does limit our ability to see some of the bigger broader picture of overall movement enhancement through the individual that might be able to accomplish a big chunk of that work without …
Til Luchau:
That’s true.
Whitney Lowe:
… irritating the local structure.
Til Luchau:
Maybe we’re setting people up to go out in their life and live in a way that helps the issue. There’s less emphasis on taking care of it all right there on the table and getting our resolve right there.
Whitney Lowe:
Yup, absolutely.
Til Luchau:
Anything else from your side on what helps and [crosstalk 00:56:01]?
Whitney Lowe:
No. I think we’ve drilled down into some fascinating and great stuff there. Of course, we can explore a number of these things in greater detail, which we probably will do in some future episodes and come back and revisit some of these things that can assure us.
Til Luchau:
Yeah, I’m already making [crosstalk 00:56:15]. That’s right. Well, I know you have some very specific shoulder courses in your repertory.
Whitney Lowe:
Yeah. You’ve got a good comprehensive shoulder course in our online orthopedic massage problem, where we delve into a lot of these things in great detail. You do as well, right, over there?
Til Luchau:
Well, right. Both a one-hour short versions, but then a larger principles version. There’s also Diane Makowski’s shoulder jam coming up. We’ll put links to all that stuff in our show notes. Should I jump into our closing messages there, you think?
Whitney Lowe:
Yeah. Do we have a closing sponsor message here today?
Til Luchau:
Closing sponsor today is Handspring Publishing. When I was looking for a publisher for a book that I wanted to write, I was lucky enough to ended up with two offers, one from a huge international media conglomerate. I’m not kidding you, and the other from Handspring, a small publisher in Scotland run by four great people. I’m glad I chose them, Handspring. Because not only did they help me make the books I wanted to share, the advanced myofascial techniques series.
Til Luchau:
By the way, it’s volume one that has four chapters on the shoulder and covers a lot of the techniques I’m going to put in the handout. Their catalog has emerged as one of the leading collections of professional level books written especially for bodyworkers, movement teachers, and all professionals who use movement or touch to help their patients achieve wellness.
Whitney Lowe:
Yes. Handspring’s Moved To learn webinars are free, 45-minute broadcasts featuring their authors, including a recent one with Robert Schleip and Jan Wilke talking about the new edition of fashion in sport and movement, where they share new research on hot topics such as kettlebell training, foam rolling, fascias role in sensation, and more. Head on over to their website at handspringpublishing.com to check those out. Be sure to use the code TTP at checkout for a discount. We thank you, Handspring.
Whitney Lowe:
Thanks to all our sponsors. If you can stop by our sites for the handout we mentioned for show notes, transcripts, and extras, you can pick up links to that also from my website at academyofclinicalmassage.com. Til, also, on your site there, which … Where is that?
Til Luchau:
Advanced-trainings.com. We love to hear from you. Email us your questions or things you want to hear us talk about at [email protected] or look for us on social media, just my name, @tilluchau. How about you, Whitney? Where do people find you?
Whitney Lowe:
People can find me also on social media under my name, Whitney Lowe there as well. We do encourage you also to follow us on Spotify, Stitcher, or your favorite podcast platform of choice, whatever that is, rate us on Apple podcasts or wherever else you happen to listen. If you’re unable to find it in any of those locations, you can always grab a copy of Pink Floyd’s Dark Side of the Moon and play it backwards 1078 RPM turntable and hear us there.
Til Luchau:
Is that true? I didn’t know that.
Whitney Lowe:
It is true. It is true. I tried it, yes.
Til Luchau:
I can do that.
Whitney Lowe:
Yeah.
Til Luchau:
Thank you, Whitney.
Whitney Lowe:
Thank you, sir. Enjoyed it. We will see you again in two weeks.
Til Luchau:
Okay.
