 Yes, welcome back to Think Tech, you know, and we have Christine Linders with us. She's a physical therapist. The final of our show is physical therapy above the waist. Very provocative. And our tagline is what to do about shoulder injuries. We're going to learn about that today. But first, a little music to get you into mood. The first song has to do with shoulders, of course. We're only going to sing 20 seconds of it. Ready, Christine? I'm ready, Jay. Put your head on my shoulder. Hold me in your arms, baby. Have you thought about a music show? Never mind. Not even embarrassed, right? But I didn't know this actually opens up the whole idea about shoulders. It does. Shoulders are important. Shoulders are a part of our frame that's strong. It's part of the infrastructure of the human body. It is. And therefore, for example, put your head on my shoulders means I will support you. I will support you. It's a strong place. We carry things there. We carry things on our shoulders. It's important to keep our shoulders in good condition. It is. So if you don't, for example, if you're moving, you get the shot moving like that, you're going to throw off the balance and the rest of your body. That's right. That's right, Jay. And that will affect you below the waist as well. That is true. That is true. So the next song is 57 Ways to Injure Your Shoulder, just like the ketchup bottle. That's right. That's 57 sauce. There's 57 ways to injure your shoulder. And we definitely do not know them when we're going about our day. Okay, that's why we made this a very long show. Now it's not 57 Ways. You actually calculated it. My palms are sweating, Jay. There's many ways to hurt your shoulder. There are usually ways that we don't think of when people hurt their shoulder, like carrying your purse always on one side. Or your briefcase. Or luggage. Reaching in the back seat of the car. If you're the driver, you're always using that arm to reach backwards. That puts your rotator cuff at risk. Talking on your phone all the time with your arm pinched in there, takes the bicep tendon where it runs up across your arm into your shoulder joint and pinches it under the arch in your shoulder there. So that's a problem. Your nerves react. Yeah, well, it's a tendon. It's a tendon that gets pinched and that's where people get bicep tendonitis, which is a very painful thing up here in the front of your shoulder. They also get bicep tendonitis if they're using their mouse on their laptop or without their arm supported or holding their phone out where the bicep tendon is always loaded. Those are times when you don't know you have tendonitis. So you wake up one day and you're like, oh my gosh, my arm hurts. You think, what did I do? But it wasn't like you just reached in the back seat of the car and said, ow. It was the, I sit with my arm out unsupported all day long using the mouse. We're using the blackberry. We're tending to something while you're reaching. Some flight attendants will get it as they're pushing luggage up over and over and over again where that tendon gets pinched. You didn't just hurt it doing one thing because when you do one thing, you know you're hurting. It hurts. You wake up, it hurts and it hurts bad and you're not sure why. And those are the 57 ways to hurt your shoulder that we need to call attention to so we could mix it up right to left, carry your purse on your left, switch to your briefcase to your left. The mouse is difficult because desk setups are desk setups and even for left-handed people, I know many of them, they eventually learn to use it on the right most times because of the way desks are set up and where things are. Some people shift it if they have pain in their arm and they'll learn to use it with their left to give their right arm a break. That's a little bit more challenging. Some of my best friends actually are left-handed. Smart people. My brother's left-handed. He is a smart person. I could show you how to be left-handed. But, you know, this goes to the question of, so you're really saying in here, and we'll cover it in greater detail, is you have to switch or at least be mindful of the fact that you're pressing one side out. That's correct. And so you should switch. That's the best thing. But what I think people need to know about it is when you're constantly having the right arm go forward or the left, if you're always doing things with your left, the ball in socket. It's like everybody refers to it as a golf ball on a tee because the socket is so small. It's not like this big. It's like this big. And so this big ball is sitting on this little tee. And so when you go forward, the ball goes forward. And all the muscles, your rotator cuff tendon, your supraspinatus, that hold onto the ball, is now reaching forward to hold onto the ball, which puts it under a constant strain, as well as when the ball moves forward on the tee, the bicep tendon that is the number one dynamic restraint to the shoulder moving forward is constantly under load. So the brain is giving messages saying, stay on, stay on, stay on. The bone is moving forward. We need a restraint to resist that bone moving forward. But when you are reaching forward all the time for the mouse, you don't think about the ball moving forward. And over three or four or five years, the ball is forward. Your shoulder is a little bit more dipped forward on one side versus the other. And now you're setting yourself up for a risk for pain and injury, or you already have pain and injury. Are you saying not to play golf? No. Definitely play your sports golf, tennis, go paddling, go surfing. But you know it's just one side only. If I'm like a left-handed hitter, I'm a right-handed hitter. You're a right-handed hitter. Okay. And I'm only on my right side. I'm stressing out the shoulder right here. Oh, should I change the left hand? No, that you shouldn't do because that you're not doing for hours and hours and hours on end. You're not swinging a golf club for eight hours like you're reaching forward for your mouse button. You're doing it. And as long as you do some of these exercises that I'll show at the end today, you undo the sport, undo the task, undo the activity. Excuse me. Activity. So when you can switch like a purse, a briefcase, if you drive with one arm all the time, that's another one. I do like to drive with my left hand. I switch because it gets sore in the front of my shoulder. That's the bicep tendon. I'm pinching it because I'm up here. So you just switch. There's times when you could switch as you should. This was a torture. It wasn't no really. You're supposed to hold your arms out like that forever. I make that analogy to my patients where I say there's contests at Oktoberfest where you hold a stein out here and they give people like a hundred bucks whoever can hold it. But you watch, they all stand out here. And then it starts lowering. And then they're like, oh, and they drop it because the tendon can't withstand the load for a long period of time. You could hurt yourself. So have you covered all the ways, you know, that we could have a shoulder injury? No, there's other ways. I know we didn't do 57, but maybe we did five. We did probably five or six, I think. And reaching behind your back for women that do their bra, that's one of the complaints I get with people with shoulder injuries. And I know you can't understand that. Yeah, I'm trouble visualizing that, but okay. Well, what if that person isn't married? Or what if they do live alone? And I've had five shoulder surgeries. So since I was 18 years old, I've had to hook it in the front and spin it around because my shoulders got repaired and I couldn't do it. And so I tell them, I know that's how you've always done it. Let me show you a new way. Switch them around. You will not hurt your shoulder that way, especially if your shoulder is already injured. You want to avoid some of those things that are aggravating it so that it heals and then you can get back to doing it behind your back. But there's times that you need to avoid the irritating maneuver so that the tissue doesn't have any irritation on it so it can heal and get back to normal. You know, what this really teaches us, and I think we should stress it, is that you have to be aware of how your body is working. Movement. Muscular in terms of, you know, skeleton and, you know, engagement. You have to think about these things otherwise you're going to wind up with a surprise. You do. Movement matters. I was going to plug this show. Movement matters. That's going to be in the final exam. Movement matters. Movement matters. If you're aware of how you move and you move better, you get to feel better. And that's what's important, or you get to never have a shoulder injury because you're aware that your shoulder is forward than the other. People notice it in pictures that, oh my gosh, I didn't see that before. I notice I've been getting more and more crooked. It is normal for the dominant arm to be a little lower. Some people in Washington already are. That's true. Yeah. Anyway, so, you know, one other thing that we should mention before we get off the, you know, what causes injury to shoulder is a simple, you know, traumatic accident. Yeah. Car accident. All down. Yeah. In so many ways, you could hurt your shoulder right there. You can hurt your shoulder that way. Pretty serious injury. Serious injuries from falls could be a fracture of, this is the humerus, the shoulder bone, a fracture of the humeral head, which is up here. You can shatter the bone. A lot of people break the humeral head when they fall. You can tear the other structures like your rotator cuff or the labrum, which is a cartilage ring that goes around the ball in the socket. You can tear those things from falls. Car accidents, same thing. Rotator cuff injuries, labral tears, sprains of the ligament, strains of the muscle. Any kind of trauma like that can create a big type of injury. When we were kids, we would bury each other. You know, we would say things like, give me all you got. And the idea was that one kid would take his fist to the other kid's shoulder. Dang, really. Suck them hard. And since the shoulder is a strong piece of gear, usually that wouldn't hurt a kid. But I can see it actually hurting a kid if you do it too hard. Yeah. Isn't that something that could give you a serious injury? It can give you injury. It'll definitely traumatize the muscle in the region and start the process of inflammation. Young kids are tough, so the next day, whatever injury they have from a punch, usually is gone unless it dislocates the shoulder because you actually punch it too hard, in which case that's going to be a serious injury from a punch. You said something interesting I want to unpack. That aren't the process of injury. Kind of a process. It can be a process. A little bit of an injury can turn into a bigger piece of an injury, right? That is right. And that's what I tell people that come into the clinic. Sometimes they're in for something else, like neck pain or back pain. And I'm talking to them about posture and I'm noticing asymmetries in where their shoulders are. The dominant side tends to be a little lower. That's normal, but they shouldn't be more forward. And when it gets more forward, that's when you have that process like, okay, I'm reaching to open up the fridge. I'm reaching to tie my shoes. I'm reaching to get something off the counter. Midnight trips to the fridge are a bad idea. Ice cream. On multiple levels. Stop doing it. But that's the process. You have a little bit of a tinge in there that starts an inflammation process. And you don't really know it's there because you don't have pain yet. It's not enough for your brain to register that there's something wrong. Then you keep doing normal everyday things, reaching for the fridge, reaching in the backseat of the car, working on your computer, holding your phone, doing dishes, picking up heavy pots. And pretty soon there's pain. And you didn't know because you didn't fall. You didn't swing at baseball and say, oh, that hurt my arm. You didn't do anything new where there was pain right away. So you don't know it. Did I sleep wrong? Let me see. What did I do? Those are the process injuries. You weren't thinking about it. You weren't in touch with your own shoulder. It was a little bit over time until the straw broke the camel's back. Let's talk about the straw and the camel's back. Suppose I do have a shoulder injury and I haven't watched this video. I haven't watched this video. I know nothing about this process that you're describing. And it keeps getting worse. And what is the worst case analysis for a little injury that I repeat the bad motion? What can happen to me? How bad can it get? It can get bad to where people feel like they can't use their arm. We use a pain scale, 0 to 10, 10 is emergency room pain. And people come in and say, oh, my shoulder hurts so bad, I can't sleep at night. I can't even grab and turn the sink on. I can't pinch the button to like do my pants. That's where it gets so bad that you can cause micro tearing of, say, your rotator cuff. It causes a little bit of a substance tear in the tendon or the muscle from that constant abuse. And you need to... People usually get... You need to be able to pull up your pants. You need to be able to pull up your pants. That's very important. In this society we do... In this social world, you know, you get terrible criticism. You could lose your job and among other things. It is, it is. Yeah, that's something that we need to do. But the problem with that is that now people can't use their arm, that people can't work, people can't do the activities that they need. And sometimes you just shut the arm down where whatever activity... It's not that you need a sling if you don't have a tear but you have micro tears that are causing this pain and inflammation. Shutting it down, meaning now you need to use your left hand to open up the fridge. So now you're imbalanced. You're imbalancing even more and putting the other one at risk while you heal this one because as soon as you do the one activity that irritates your shoulder, now you're back to flaring it. You might have to shut it down for a week. You might have to shut it down for two. It might take three. How about forever? Can this be a forever injury? I would like to say no. If we're causing repetitive injuries, no. Everybody's always that I've seen has been able to get back to doing what they want to do. It sometimes takes way longer for others. My job, I'm working with people when I get 10 to 90 say things I back off but I'm still working so I try to take it easy the best I can and it takes longer for me because I'm still using both of my arms. But if you had a desk job you could support your arm. You could rearrange things. You could carry the briefcase on the other hand. You could lighten the load and only take the bare minimum. Part of the consciousness thing. We can take a short break. It's a neat little division into what is a shoulder injury, how you avoid having a shoulder injury and if we get back from this break I want to talk about how you fix them with physical therapy. This is very important and we do have pictures. We'll be right back. Hawaii Energy The Hawaii Energy Policy Forum Hawaiian Electric Company Integrated Security Technologies Galen Ho of BAE Systems Kamehameha Schools MW Group The Shidler Family Foundation The Sydney Stern Memorial Trust Volo Foundation Yuriko J. Sugimura Thanks so much to you all. Christine Linders, write that down. This is all going to be in the final exam. Okay, so Christine, let's assume we have a shoulder injury. Let's assume we're not conscious at the time we got it. I mean, of a body movement. Not conscious that it was getting worse. And here we are and we need some heavy lifting. That's a bad expression. We need some serious correction for healing of our shoulder injury because it can get to be a real pain. What can you do with the magic of physical therapy to make my shoulder better? Don't forget your pictures. Before we get to the pictures, when you come into the office, I pay attention to things like one shoulder being more forward than the other or your shoulder blade in the back. I put you through a range of motion to see what it looks like if it's performing optimally because a lot of times the muscles in the back get weak as you're using your arm forward and you don't know it because they're back there. You don't think of them. And a lot of times you have to strengthen those to make the front part or the outside part feel better. So what I can do when you get to the clinic, the first thing I usually go after is the pec minor. That's a muscle that attaches from the front of your rib cage into the front of your shoulder blade which is in the back. It's a little bone that sticks out that it attaches to and when it gets short because you're reaching forward, holding your phone... Between my arm and my chest, right? You feel it right there. I got it. I got it. I got it right there. That's the one. If you release that pretty soon, the shoulder that was forward like this is now sitting back where it should be and then the shoulder blade in the back is now sitting on the rib cage where it should be. So there's no more tension on your bicep tendon and no more rotator cuff that's reaching out to hold that bone. You said release. How do you release? I'll do some soft tissue massage to it to loosen it up. It usually feels... I check full sides because I want the person to know that I'm not just going after something that is not a problem and I don't think I've ever had someone that I poked in their painful side that they said, ooh, that feels good. They usually say, oh my gosh, why does it only hurt on that side? And I explain that... That's a tip-off right there. That's the tip-off and I want you to know when you're laying on my table that that's why I'm going to go after that and help to resolve it because your other side, while it may be a little tender, doesn't feel anywhere close to as bad as the side that's affected or painful. What, no question. Yes. Just suppose I go for this... What is it again? Soft tissue massage or mobility, as we call it. And we find, to our amazement after watching this video, they both tight. I loosen them both up. I loosen them both up. I loosen them both up. Because in that instance, I'm usually looking at someone that's sitting kind of rounded like this. So their miners are going... Pectoralis is the name of the muscle. Pectoralis minor. It is going to be in a shortened position prolonged if they're like that. So I have them lay down. I have a picture at the end and I'll show you where I just loosen people and listen to them. Oh, yeah, that's the word. Afterward, they all get up and say, oh my gosh, wow, I feel more open. They open is the most commonly heard thing after I loosen up someone is I feel more open. Yeah. Right. I need to enable them to get up here because we can try to make you sit up straight all day long. But if you've got these two little muscles holding you like this, it's just, it's hard to get up there. It affects your posture. And your posture is so important, you know, for everything. Your state of mind, among other things. Everything. So you're needing the muscle there. I need the muscle. I loosen it up. I stretch it. Sometimes I bend it back and forth. I'll get lotion and loosen it up. Depends on how tender. Someone's very tender. I go very easy. I'm not trying to make you suffer. He's not necessarily an answer here. No. Suffering's not the answer. The mnemonics for PT have been pain and torture. Physical, they have all different names for therapists that involve torturists. And so, oh, I'm going to my PT. You're not into that. Yeah. It's going to hurt. I tell them, if this hurts, I'm sorry. I'm just going to go as easy as I can. You let me know when you need a break. We don't have to fix it today. How long does it take you to meet it so that I feel open? It takes me somewhere from two to three minutes to five or six minutes. And I don't usually blast away in one shot. I try to give them enough, because the tissue likes to be open. It gets blood flow and circulation more stretchiness, extensibility, we call it. So that the next time they come, I can do a little bit more. It's a process to undo it, as well as it is a process to do it. Next time they come, let's dwell on that. Time to Okay. So for time one, I will loosen up their area. And then can we get to a picture that's later in the order? Make that call. Okay. So let's go to picture number five. Okay. So picture number five. This is a model laying on a rolled up towel on a wall. So I will release the wall to do this. No, it needs to run from your head down to your buttocks. So it's running down. It's not across your back. It's straight down your back. It's hard to see because the towel squished. But a half foam roller that's 36 inches which runs from your head to your buttocks or a full one. Circular one. Circular one, yeah. Could it be a semi-circle? Circular or semi-circle? Doesn't matter. Absolutely. Semi-circular I'll use for older bump balance. Yeah. So I stretch them out sometimes on this. It depends on who's there and their age and all that. Muscle extensibility. And then I will stretch them out on this and have them do deep breast because your pectoralis minor does attach to your ribs. Breathe in, the muscle gets tight. Breathe out is no more. Breathing is part of this too. Breathing is always part of exercise, isn't it? Breathing is always part of exercise. Breathing, we can't do anything if you don't breathe. That's true. I apologize for that. So after that, we're still in the first session. After that, I'll go to picture number six. Okay. That's it. So now, if you have the range of motion and you don't have a rotator cuff to air or shoulder pain, I'll have them rotate their hands back, pressing their hands towards the floor, which now is an inhibitory stretch to the pectoralis minor and major and also squeezes the shoulder blades so that's what we're doing here. And also squeezes the shoulder blades. So now we're starting to re-educate. So I will send them home with something like this, whether they lay on the floor, lay on the bed, try to start stretching out. They can stand up against the wall and do that as well, which is picture number four. So now you're at work and you want to try to squeeze your shoulder blades. This person looks very familiar to me. You know, I feel like then people can't really tell you. There were Queen Tuplets in her family. I don't have to have them sign a release if they look someone like me. Very good. So that you could squeeze your hands back, squeeze your shoulder blades back into a wall. If you're at work, if you're at home, if you're out in a shopping mall and you're having trouble, you could squeeze back and that's the part of re-educating after I stretch out the front. Now you need to start re-educating the back. Now that they're a little bit looser, I've released some things so their shoulder pain is less or hopefully at least gone when they're at rest. I will now give them something like picture number seven which is something with a band or not. So now you could see the shoulder blades squeezed in the back. So what people I think oftentimes the ones I see in the office anyway don't realize is, oh wait, I don't realize I have to use the back muscles to save the shoulder. So all the shoulder blades from your shoulder blade to the right and to the left they are the rotator cuff muscles and they attach to the shoulder the ball, the ball on the socket. The muscles in between the shoulder blades right in the middle of the back where you could see the little wrinkles those are the muscles that control the shoulder blades. Now we have muscles that control the shoulder blades in the center muscle that controls the shoulder on the back to the shoulder blade. They're helping your posture and opening you up. They strengthen and reeducate those tissue. Not everybody can use a band if someone rotates out and they have pain. That's orange thing is the band. It's a stretchy band. That's the stretchy band. So you're stressing the back muscles all the more because of the band. That's right. It's like weight lifting but I use a very light band in the beginning because they did have a shoulder injury and those are shoulder muscles too so I don't want any pain. This is not a no pain, no gain. There's pain free that should exercise only open your hands as far as you don't have shoulder pain. We start there. I've had people where we had to start with a squeeze and only open the hands a little bit and then the next couple of times they say, oh my gosh I can open it now let me try a band. I can do this at home just as well. You could do it at home you could do it in the car you could do it sitting right there I should have brought a band. I am doing it sitting right there. Good, see? Yeah. So how many times do I have to do it if I had the right effect? Just one set of reps. No. I tell people that are at a desk I say I don't care what you do every hour if you do one or two with or without the band then you go back to your desk one or two later back to your desk some people will do ten they say no I'm going to do ten three times a day I'll do it at ten after I've been working for two hours I'm going to do it at one after lunch when I go back to my desk I'm going to do it at four right before I go home I'm going to go out from them what is best for you is it better to do two of these two of these or will you have time in your day that you can actually take 15 seconds and do ten and then go back to work re-educating the proper posture re-educating time watch everything computers have programs that you can set alerts like stand up walk around for three seconds there's things apps and everything that you can set up on computers time or keep resetting it sounds like something you can do for carpal tunnel too with the bands no standing up every ten minutes standing up and giving yourself a break with the carpal tunnel things people tend to have their hands moving all the time like you see me doing and so it's helpful to take a break so if you are typing all the time and you're resting that area around the carpal tunnel over your the little bumpers they have right before you use the keyboard if you're resting on there don't take your hand off and rest it hang it down let the arm rest you just don't want to keep anything compromising and compressing the area of the carpal tunnel but we don't think about that while we're resting we just keep our hands on the laptop while we're talking just take them off and give them a break okay dark side now dark side so I know a guy not too long ago we had to have surgery had to have surgery on his rotator cuff which happens I mean it's an aging thing maybe it's something I don't know what he did deserve that and he was walking around with a sling for a long time so how does that happen and what is the relationship between the kind of injuries that we talked about here and you know a need for surgery on his rotator cuff yeah so did he injure himself or did he just have one of those oh I don't know how I did it my shoulder hurts and I yeah so I don't know how I did it my shoulder hurts repetitive injury where you're doing something reaching all the time and then you're reaching in the back seat and then you're sleeping on that arm or you're sleeping with your arm up here and that's compressing the rotator cuff up under that bony arch and it gets some sort of internal infringement where the bone up here that bumpy bone on the top of your shoulder underneath it is poking into the soft tissue creating overtime like macerating a steak or something it creates micro tears that leads to an eventual weakening of that rotator cuff muscle and then you go to pick up your soda bottle and boom you have a rotator cuff to air it's just been waiting to happen how can you tell that it's that rather than you know muscular tightness I ask questions and when you come in to see me so sometimes I don't see people before surgery they're coming in after surgery and they're in the sling and their shoulder is forward and their shoulder blade is winging off the back which some people have seen I don't have a photo of that I used to have it and now I've strengthened myself so I I tried to provide that for you guys but I'm sorry next time but the shoulder blade is winging off the back because of the position of that short pectoralis minor and being in the sling so at that point I don't know where they like that before until I start rehabilitating their shoulder getting them range of motion getting them into the back posture and then asking them were you always doing this at work what was their task are you a baseball player are you talking on your phone all the time is there a hobby that you like to do that puts your arm like that all the time and now it broke down because of wear and tear I find that out through the process of my interview with them what I hear you saying is probably before you rush off and have your rotator cuff you probably want to see a physical therapist to make sure that this isn't something that can be corrected with a lot less invasive procedure what not that's the main point right there write that down because that's on the final exam that's the final exam not because I thought so because she thought so if you have a rotator cuff tear go see a physical therapist fix your posture get the reeducation exercises even if it's without a band to normalize the position of your shoulder strengthen the muscles on the back of your shoulder before you consider getting the tear because there's things called copers and non copers I've seen people with invasive rotator cuff tears that went in for the day of surgery for their pre-op with the nurse and that day they said well wait how's your shoulder and one of my patients in New York City said oh well it's fine I've been doing some strength training I didn't meet him before and now I'm fine and she went I think we should cancel the surgery she had him raise his arm it was fine and she told him you're a coper so he came into physical therapy with me later this was a wear and tear but it was one of those massive through and through tears that need surgery you would think most people would need surgery but there's copers and non copers sometimes things are not what they seem to be that's right that's Christine Lenders and you're going to see more of her right Christine is going to do her own show about this and we're going to see a lot of other kind of below the waist and above the waist and 57 things to do this and 57 things to do that but she will move on to the same here Christine Lenders Wow Physical Therapist wow Thank you Thank You