The Hand to Shoulder Solution

Ep 17 - The Hidden Truth About Shoulder Injuries: What Therapists Wish You Knew

• Carl Petitto

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Today’s discussion unpacks the complexities of shoulder pain, focusing on conditions like rotator cuff tears and managing pain effectively. We explore effective strategies for strengthening, utilizing heat and cold, and the importance of targeted exercises in recovery.

• Understanding rotator cuff functionality and common injuries 
• Identifying key factors that contribute to shoulder pain 
• The role of targeted exercises in shoulder rehabilitation 
• Strategies for using heat and cold for pain management 
• Empowering patients through education and self-care techniques 


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Hello and welcome to the new show, The Hand to Shoulder Solution, with me, Carl Petitto.

If you are experiencing pain in your arms and hands, this is your resource.

Subscribe, listen, and share to help us give pain the middle finger for good!

This is a resource to help you mitigate pain at home and become more educated on what to ask your doctors and therapists. No medical advice will be given, and you should always see your medical professional for any questions.

Thank you, and welcome to the show!

Speaker 1:

Welcome back to the Hand-to-Shoulder Solution. I'm Carl Petito, your host. I'm an occupational therapist and a board-certified hand therapist. I specialize in the rehabilitation of orthopedic conditions affecting the fingertips through the shoulder, and today we're talking about the shoulder. I want to go through some more details, but first I want to mention that this is not treatment or advice on treatment. This is basic information so that you can be empowered to make the right decisions for yourself and understand when and why you should be seen by an orthopedic surgeon, a physician assistant, an occupational therapist, a hand therapist, etc. It's very important that you be thoroughly evaluated, have a thorough examination by a healthcare practitioner so we can really get to the bottom of what is causing the pain, so they get the specific treatment that you need. Timing is everything, as with most things. The sooner that you can get a problem taken care of, the easier it is to fix and also have a better outcome and, of course, in a shorter period of time. So, talking about the shoulder, I want to talk about how do I, as a hand therapist, as an occupational therapist and certified hand therapist, how do I treat some of these conditions and why do we do some of the things that we do and also positions, and why do we do some of the things that we do and also how do we figure it out. So one of the things is the rotator cuff tear and it's a term that's thrown around a lot, that you might hear quite a bit the rotator cuff. I have a cuff tear etc. And that's literally a tear of the muscle fibers and or the tendon which connects muscle to the bone. So if you look at the rotator cuff, this is the front portion of the shoulder blade. If we turn it around and look at the back of the shoulder, we have the shoulder blade and then the ball of the ball and socket where the ball is part of the humerus, your upper arm bone. That inserts onto the socket and the muscles of the rotator cuff C-U-F-F. They provide stability to the joint and they keep the ball centered on the very shallow socket that I outlined in previous videos. So they have to work together as a team to keep the structure all in alignment.

Speaker 1:

Now, whether it be a traumatic injury or from wear and tear, sometimes these muscles and their attachments might suffer a small tear, which would be a partial tear, or a full thickness tear Upwards of 20% of people who have a tear don't know that they have a tear, meaning you don't always need to have surgery for this. Sometimes multiple muscles can be torn and in severe situations these will immediately go to surgery for repair and the surgeon oftentimes surgery now is orthoscopic, meaning they'll make a couple of small holes. They'll go on with tiny cameras and tools and make the repairs without opening up the whole structure and you have quicker recovery. You have less inflammation, less pain about. Let's talk about therapy. So, going to the therapist's office, we will do specific orthopedic testing and resist certain muscles to see what what positions cause pain. That helps me narrow down exactly what muscle muscles are involved. I'll also palpate or feel the muscles and feel for knots, for tightness, and those knots, by the way, are called trigger points. So if you take a length of rope and you tie a knot in it, that shortens the length of rope. So if there's knots of the muscle or just really tight areas or trigger points in the muscle, that is shortening the muscle and then compromising the mechanics of the whole shoulder, because now you have one or two or more muscles that are too tight, they're pulling too hard in certain areas and it's throwing off all the mechanics and then making some structures, bony structures, hit each other, causing tendonitis and other inflammatory conditions that will cause further pain. So it's very important to be seen in the clinic so we can unravel that and figure it out and determine what is the best course of action, what is the best treatment or combination of treatments.

Speaker 1:

Now, when you're taking a look, for example, at a rotator cuff tear, the most commonly torn muscle is supraspinatus and that muscle fibers and its tendon travels underneath that roof of bone called the acromion. And you can watch on previous episodes where we go over this in quite detail that roof of bone, go over this in quite detail, that roof of bone and then this muscle that travels underneath that roof of bone right here that gets pinched off and sometimes it will actually wear a hole in the muscle. Sometimes in this, in the center of the, the flat tendon that connects the muscle to the outside part of the ball, and that one muscle begins the motion of raising the arm up to the side. Now other muscles can take over for that, but what we need to do is strengthen the surrounding shoulder girdle and rotator cuff. So the rotator cuff, c-u-f-f, four muscles and they are wrapped around the shoulder pretty tightly and then the muscles of the shoulder girdle which they're not shown on here on the model. Again, this is the back of the shoulder but the muscles will go up to the neck. The cervical spine Muscles also travel down the rib cage and there's the whole group groupings of muscles actually work to stabilize and to help move the shoulder.

Speaker 1:

Also, these teams of muscles, there are specific teams or groups of muscles that will work to raise that roof of bone, the acromion bone, and lower the ball, the head of the humerus, to maximize the space where the tendons remember tendons connect muscle to bone. Where the tendons travel to connect the muscles to the bones, they don't get those pitched off and severed. So what the therapist will do is a thorough examination to determine, determine the biomechanics or what exactly is going on, good and bad and maximize the good and of course, minimize the bad. So we will prescribe specific exercises for the patient to do at home and we'll issue resistive bands, for example to fix on the doorknob on the other side of the door, shut it right in the door, and perform specific exercises to strengthen very specific muscles, to stabilize the shoulder and reverse what is happening, rotator cuff tendonitis, for example. And remember, itis means inflammation, tendonitis is inflammation of the tendon. So I will educate patients how to properly ice the specific tendons. And we can do that very targeted with an ice cube. Often I'll have people just get a paper Dixie cup and fill it with water and freeze it and then peel off the top of the cup and then you have a handle now and you have the ice to glide on a specific portion of the shoulder. It can be very targeted.

Speaker 1:

The problem with the ice pack is it covers a lot of area. Almost all of the time the muscles around the shoulder girdle the rotator cuff, especially the muscles that elevate the shoulder blade or raise the shoulder blade. They become very, very tight. You know we carry our stress there, tense up and when there's pain in the shoulder and around the shoulder area, muscles become tense because naturally it's guarding, it's trying to stabilize itself. So the surrounding musculature will get very, very tight. So what does cold do to things? Cold shrinks. So if we put cold on there it'll numb it up and make it feel better. But then the after effect is now it hurts a lot more because now these tight muscles are shrinking and they're pulling really hard and now they're tighter.

Speaker 1:

So the tendon is not muscle, the tendon connects muscle to the bone. So if the tendon is inflamed we can take a piece of ice which is very targeted and, for example, just put that ice on the outside. The white part is tendon, the red part is muscle. So I will have patients glide a piece of ice directly on the skin. I'll actually teach them how to palpate or feel themselves where that roof of bone is and then they step off an edge and then they're right on onto the tendon and they'll feel that that's quite tender. Same with the biceps tendon in the front.

Speaker 1:

So let's say, for example, we're going to work to decrease tendonitis of the biceps tendon, going to work to decrease tendonitis of the biceps tendon, which is right here, this whitish tissue, and then also the subacromial bursa, which we talked about bursitis before, and that subacromial bursa, that flat water balloon, sort of shock absorber that lives underneath that roof of bone, the acromion and the tendons of the rotator cuff which will be on the side of the shoulder. So I will have a patient and this should take 10 seconds, 10 to 15 seconds each location. They put the ice. So I'll have them rest their hand on their lap, apply the ice to the front bony part of the shoulder, then also around to the side, on the top side of the shoulder. After that's deeply cold, I'll then put their hand behind their back, which rolls the ball forward and pulls that flat water balloon or the bursa sack forward. It exposes it, so we have to get it out from underneath that roof of bones so we can have access to it, so we can get the ice on it and then just barely touch the skin, get it deeply cold again, and then they're done. So it should take a total of a minute, minute and a half, and that done at lunchtime, you know, midday and at the end of the day before bed, some severe cases. If time allows patients I'll have them use the ice midday, after dinner and also before bed, and that I found that to be most effective for decreasing inflammation and fully resolving the problem.

Speaker 1:

Now it's very important though, especially with the shoulder, the location of the ice. It has to be very specific, and that's what the therapist will talk to the patient through, and what I like to do is use the patient's cell phone. So I always ask people to bring your cell phone to your visit. I like to use your phone to do a video of what I recommend. You know the exercises, the icing, proper placement of heat, proper timing, and I can explain on the video that they can just reference the video anytime they want to. So let's talk about heat. So heat expands If we go back to the muscles, having a tight knot in the muscle or a tight area which is called the trigger point.

Speaker 1:

Now let's look at the muscles. So here's the back of the shoulder blade and let's say there's a really tight area and I'm sure you've felt it in yourself where there's just especially if you've gotten a massage and the massage therapist gets to an area where that just sends you into orbit and that's really tender. That's called a trigger point. So again, if you put ice on that it's going to shrink it. So if you shrink it you're tightening it and you're making it worse. So the heat will allow that to relax and allow the tissues to lengthen out. Now you can overdo anything, you can overdose on heat. So I usually have patients just apply an electric heating pad on the lowest setting for the shoulder sometimes lower medium setting for a period of 15 minutes, two to three times a day, not more than two or three times a day. Some people will assume that more is better and get in the shower and make it as hot as they can tolerate. That's just way too much. That's increasing inflammation and, moreover, it's covering everything, including the tendons that are inflamed, and then that's going to make that inflammation worse. So it has to be targeted, it has to be a steady temperature, it has to be the correct location Very, very crucial.

Speaker 1:

I want to talk about the go back to the biceps tendon. The biceps tendon. There's two heads to the biceps. There's a short head and a long head. So that long head is connected with a tendon that goes through this what's called a bicipital groove. It goes up over the top of the ball and inserts on the top of the socket. Now that gets really, really inflamed, and the way that that is tested is with what's called speeds test give resistance and then then also I'll I'll palpate that tendon and I'll move the patient's arm side to side, so that tendon is rolling under my finger, and I'll move the the arm side to side, like so and the tendon is rolling under my finger, and I'll see if that's has a lot of point tenderness. Also, there's another test called the Urethane's test.

Speaker 1:

It's interesting that the biceps is the prime mover or the primary muscle that moves the forearm into supination. When you palm up, that's supination. When you turn a palm down, that's pronation. So palm down, the radius flips over the top of the ulna, which we talked about in previous episodes about the forearm and wrist, and then when you turn a palm up, biceps is turning a palm up like that along with some other muscles, but the primary muscle for turning a palm up is the biceps. So there's a lot of action down low, closer toward the wrist, and then up high. Now what I want to do with that? Usually that biceps muscle also gets very tight. So what I will do is I will bend the elbow, hold the muscle and straighten the elbow and lengthen the muscle underneath my fingers, and I'll do that in the clinic Also. I'll teach people how to use a golf club or a dowel rod, a stick, a stick, and they'll keep their palm forward and push their arms straight back with a stick to lightly stretch that biceps and that will actually increase blood flow to that. So if you bring more blood flow, that means you're bringing more oxygen and nutrients to the diseased tissue and we'll get that to heal quicker.

Speaker 1:

So, without getting into too much detail, I just want folks to know that there is a lot that can be done, so a lot of. I see a lot of patients that come into the clinic and say things like yeah, you know, this has been going on for six months. Some people will say it's been going on to some extent for a year, but now over the last month or two it's beginning a lot worse. And you know, I didn't want to do anything but I didn't want to come in because I just figured there's not much that we can do for it. But it never hurts to ask and patients are usually quite surprised when I explain that there is a lot that we can do and it's quite easy. And coming into therapy on a often, you know, regular basis is not necessary. I usually follow up with patients once every week and a half or so and modify the home program and then, when they're in the office, I'm doing things for them that they can't normally, that they wouldn't be able to do for themselves at home.

Speaker 1:

Now, before we end this episode, I want to touch on arthritis of the shoulder. So there's a lot of musculature in the shoulder, excuse me, bony contacts in the shoulder. So where the bones contact other bones, those are wear locations. So of course you have the ball on the socket. Okay, let's show, let's show the back of the shoulder blade. So you have the ball on the socket and you have the. If we, if we turn it around and show the front of the shoulder and you have the. If we turn it around and show the front of the shoulder, we have the collarbone which meets the acromion, that roof of bone. There's a lot of movement there. Then we also have the collarbone which meets the sternum, the breastplate right here, and there's a little bit of movement there.

Speaker 1:

What I want to do is, as a therapist, is strengthen all of the surrounding muscles of the rotator cuff, the four muscles of the cuff C-U-F-F, and I want to strengthen the shoulder girdle, the muscles that go down the back, the muscles that go from the shoulder blade up to the cervical spine, the neck, and all of that gives stability to these joints.

Speaker 1:

So if I can increase the strength of the muscles surrounding a joint, then that increases stability and decreases discomfort, decreases pain.

Speaker 1:

And then also I want to teach people how to properly use heat versus cold, proper technique and timing, which we talked a little bit about before.

Speaker 1:

So I want the public to know that there is a lot that can be done to help decrease the effects of arthritis throughout the shoulder and specific strengthening as well. So for strengthening we can do repetitions back and forth and you know lifting weights, for example, lifting weights and you're moving in repetitions or you can hold the weight steady or you can use a resistive band and just hold it steady until it gets tired, and that's called isometric. So I can guide people in strengthening specific muscles for a specific location for decreased pain by just having them hold a specific position steady until fatigue sets in, which should take 10 or 15 or 20 seconds and do a couple of rounds of that a day and really make a significant difference structurally and decrease pain. So thank you for listening. I hope that really gets through to folks that there is a lot that can be done. It's relatively simple, most of the time, quite easy to do and very, very effective. Thanks for listening.