Ep 36: Beyond the Rotator Cuff: Maximizing Shoulder Health & Preventing Injury

Your shoulder functions like a golf ball balanced on a tee - a design that prioritizes mobility over stability. This episode reveals how this unique structure creates both remarkable freedom of movement and vulnerability to injury. You'll discover the critical relationship between your shoulder blade and ball-and-socket joint, and learn why coordination between these components is essential for pain-free function.

The rotator cuff, particularly the supraspinatus muscle, often faces trouble when caught between bone structures during everyday movements. Carl explains how impingement develops, what bursitis really means, and shares a surprisingly effective 15-second ice application technique that outperforms traditional methods. He also sheds light on biceps tendonitis and what actually happens during a tendon rupture.

Most importantly, walk away with practical knowledge about movements to avoid (reaching behind car seats, "empty can" exercises) and safer alternatives for strengthening your shoulder (Arnold presses, proper rows). Learn why keeping objects close to your body during lifting prevents those 200 inch-pounds of force that can damage vulnerable tissues. Whether you're dealing with current shoulder pain or want to prevent future problems, this episode provides the mechanical insights and practical tips to give shoulder pain the middle finger. Watch for upcoming opportunities to consult directly with Carl about your specific shoulder concerns.

Chapters

• 0:00 Introduction to Hand-to-Shoulder Solution
• 3:36 mpingement, Bursitis and Treatment
• 12:42 Biceps Tendonitis and Injuries
• 14:26 Exercises to Avoid and Recommend
• 16:20 Safe Lifting Techniques and Conclusion

Transcript

Speaker 1: 0:00

Welcome back. It's time for another episode of the Hand-to-Shoulder Solution. Giving Pain the Middle Finger. I'm your host, carl Petito. I'm an occupational therapist and a board-certified hand therapist. I specialize in the rehabilitation of orthopedic conditions of the hand through the shoulder. I'm also a certified ergonomic assessment specialist.

Speaker 1: 0:19

Today I want to talk about the shoulder. I want to explain some details, firstly about the mechanics of the shoulder, then things to avoid to avoid injury and also, most importantly, to optimize your shoulder health. What kind of strengthening should you do to maximize shoulder stability, to decrease pain when you go to the gym? What exercises are safe? What exercises are not safe? Reaching for objects, heavy objects? What's the best position to be in to do that? And if you can't be in the best position, what's a good tip and technique for protecting your shoulder? So let's get right into it.

Speaker 1: 0:53

I want to talk about, by the way I should introduce, this is pete. He got his name because I was treating a woman in my office and the whole skeleton was put together and he was standing very proud in the corner of the office and her little daughter was there and my patient's daughter said what's his name? I said you know he doesn't have a name. Would you like to give him one? She said I'm gonna name him Pete. And her mother looked at her and said Pete, where'd you come up with that name? And she looked at her mother, who was my, my patient, and said well, mommy, that's daddy's name, so we had some fun with that one.

Speaker 1: 1:29

Now we all know are familiar with the ball and socket, and I really want to point out, when we're talking about the mechanics of the shoulder, that's a very, very shallow socket. So a good analogy is a golf ball on a golf tee. It's a relatively big ball and then it's a very shallow socket that allows for a lot of motion and you can put your hand behind your head and rotate the ball. In the socket to put your hand behind your back, you can reach to your opposite shoulder. You can reach. There's a lot of what we call freedom of movement.

Speaker 1: 2:00

The shoulder there's two joints. It's very important to realize this and some people get intimidated about the body and it's going to be complicated and it's going to be hard to understand. No, that's that's. That's false, it's. It's quite easy to understand because the mechanics are very basic. What we can't have happening is a bone hitting another bone and pinching structures between the two bones. So if things are getting pinched or impinged, that starts causing pain in the shoulder and you're going to understand why in just a moment.

Speaker 1: 2:34

So the shoulder blade, or the scapula, sits on the rib cage. It just kind of floats there. It's controlled by muscles and it's attached to the ribs by muscles. Now this shoulder blade, it rotates up, it rotates down, it glides back. When you put your shoulder blades straight back together, it glides back toward the spine and it glides forward. All right, that's one joint of the shoulder complex. The other joint is the ball and socket. So when you raise your arm let's see if we can get this at a good angle here so when you raise your arm forward, the shoulder blade has to rotate upward. So this roof of bone right here, which is part of the shoulder blade, moves up out of the way. If that shoulder blade doesn't rock on the back of the rib cage or rotate upward, that roof of bone does not move out of the way and this happens. So the head of the humerus or the ball strikes that roof of bone. Now why is that important? Of course you don't want bone hitting bone, obviously, but one of the main reasons is the muscles of the rotator cuff C-U-F-F. The job of those muscles and there's four of them is to keep the ball centered on the socket, to keep everything located, or it prevents dislocation during movement.

Speaker 1: 4:00

Now I have this red string to show the locations on the muscles. Now I have this red string to show the locations on the muscles. So picture this divot here on the back of the shoulder blade full of a muscle, and then it turns into tendon and inserts on the head of the humerus. That muscle, when you, when you pull this, it brings the arm, it rotates it outward to the left, so it moves into the stomach. One specific muscle does that, brings the hand into the stomach, but this muscle right here in the back pulls it away from the stomach. So I'm gonna demonstrate when I go like this, for example, when I reach behind my head, that muscle, this one muscle, the rotator cuff, is one of the muscles that does that. And again, it's rotator cuff C-U-F-F, rotator, as in rotation R-O-T-A-T-O-R, so that muscle contracts, it moves in that direction. Okay, so see the position of it. This one is a little bit underneath that roof of bone.

Speaker 1: 5:01

Now, one of the main muscles and the muscle that is most commonly torn in the rotator cuff is called the supraspinatus. Supra, for it means above. It's above the spine of the scapula or the shoulder blade. Scapula is another name for shoulder blade, so this muscle lies in this trough right here on the back of the shoulder blade, goes underneath that roof of bone and inserts on the top of the ball. Now, the first 15 degrees or so of raising your arm up to the side is primarily that muscle. It's called supraspinatus muscle and if the shoulder blade is not rotating upward and that roof of bone is not moving out of the way, then you get impingement or pinching of that muscle. Sorry, pete, but you're a good sport, pete, dealing with all this. And then that starts to create tendonitis, also starts to irritate that tendon so bad that you start getting a worn spot or a tear in it. Bad that you start getting a worn spot or a tear in it now as we age.

Speaker 1: 6:18

Sometimes this bone here, the roof of bone that we've been talking about, it's also called the acromion a-c-r-o-m-i-o-n. The acromion starts to become hooked a little bit because of the head of the humerus or the ball hitting that it starts to form a hook shape, a hook shape on the edge and that also saws in. Let me get that out here. It saws into that tendon. A third thing is that a lot of patients will develop bone spurs, excuse me, and the bone spurs will saw into that tendon. One surgery is to go underneath this bone with a little router tool and smooth out those bone spurs, remove the bone spurs and then make this more of a a straight level bone as to remove the pressure from that tendon.

Speaker 1: 7:07

Okay, now there's another structure that lives under here and that's like a flat little water balloon. It's called the subacromial bursa. So a bursa sac is like a. It's a sac of fluid and if you picture a water balloon that's not full all the way and it's just kind of flat, the balloon, part of the water balloon is living tissue, then there's fluid in that. That's a little shock absorber. Okay, now when that bursa sac, or the water balloon part of the balloon, it gets very inflamed because it's rubbing here and it's getting smashed and it's getting very, very irritated. That means that's called bursitis. So remember, in previous episodes we've been talking about tendonitis, arthritis. Itis means inflammation, so bursitisitis is inflammation.

Speaker 1: 7:53

Have that bursa sack right there, easy fix for that. So we'll get back to the mechanics for a moment. When you put your hand behind your back it rotates the ball forward and guess what? It pulls that bursa sack forward so it takes it out from underneath that roof of bone so you can get to it. Then you just take an ice cube and just barely touch the skin. Ice cube as hard as a rock. You don't want to rub a rock on there, that would obviously that would aggravate it. So you just barely touch the skin. You do that hole with your hand behind your back or behind your hip. You know you don't want to hurt yourself. If you have a lot of stiffness going on, then you apply the ice directly to the skin just until it's deeply cold. It should take only 10 to 15 seconds. Studies have shown that that's more effective than an ice pack for 10 minutes. All right. So you put the ice, then you maybe lay your hand on it, just let it warm up, lay your hand gently and then one more time of ice, 10 to 20 seconds, just until it's deeply cold. And then that shrinks down the inflammation. So cold shrinks everything, okay. So the inflammation is expanded and then it shrinks down the inflammation and really reduces shoulder pain nicely.

Speaker 1: 8:56

Now, one thing I always look at and that's and it's crucial if we don't fix the mechanics of the shoulder, then this is going to continuously get compressed between here and the problem just will never go away. So more often than not, what happens is the muscles that are on your back, that, remember, the shoulder blade is attached to the ribs by muscles. Well, those muscles get tight. Or if there's knots in your muscles, or maybe you had a back rub and then there's a, there's a hard ball in there and it's just really tender and it's sore, that's called a trigger point, t-r-i-g-g-e-r a trigger point, and that could be massaged out. We're not going to get into that right now, but what I like to do is I have my patient bring your shoulder blade forward, watch my shoulder. You bring it forward and then I push on this edge of the shoulder blade until they feel a stretch. So all these muscles in here these are called the rhomboids right here get really tight frequently and I stretch those and then I'll have them clasp both their hands together. They raise the arm up and remember that shoulder blade has to rotate upward when it's coming up. So then I'll push right here and then I'll stretch those muscles and restore the movement of that shoulder blade moving up. So now watch this very important because I restored that upward rotation. That roof of bone that's been having the muscles get pinched underneath is now moving up out of the way. And then patients are shocked. You know, when they come into their movement is first, you know, only about 80 or 90 degrees of forward elevation. They can all of a sudden they can raise it way up without pain, or at least with a lot less pain. You know they're very, you know justifiably very excited that they're seeing that it's a mechanical issue. We can get the problem to fully go away Now.

Speaker 1: 10:46

Another thing is tendonitis of the biceps. So the biceps it's called bi because there's two heads of the muscle, so one head. See this groove right here. It's called the bicipital groove. It just means that the biceps tendon lives right there. So it attaches to the muscle down here. Remember, tendons connect muscle to bone. So this will go up through here and it inserts on the top of the socket. So whenever you have a tenon going through a joint which is almost non-existent except for the shoulder, here it inserts on top of the socket. This tenon starts to become frayed. You know, when it just gets irritated it's inflamed. That's tendonitis. When it starts to get frayed, like a piece of yarn starts to get frayed and it breaks down, it's called tendinosis. It's often that baseball pitchers and sometimes you know other people eventually this just breaks and it's painful when the tendon breaks, but then the pain immediately goes away and patients will often report that they felt and heard a strong popping sensation. Pop, it breaks. Okay, good, now nothing is tugging on it anymore and the pain immediately subsides. And that's okay because you have three muscles that bend the elbow. And remember biceps I mentioned earlier. Bi because it means two, two heads of the muscle. So there's another head of the muscle that inserts on the front of that bone. See that hooked bone. It's that funny-shaped bone, it's called the coracoid process and that's part of the front of the shoulder blade. So that part of the biceps inserts right there on the front of the shoulder blade and that controls things too. So one of the main things I want people to understand is that it's very important that you get to your doctor, you get to your therapist and get other things ruled out and really figure out the exact source of your shoulder pain so it can be fixed. And, like anything else, the longer you let it go, the worse it gets Now and the more difficult it is to treat what not to do.

Speaker 1: 12:46

A very common way for people to tear their rotator cuff is to reach behind the passenger seat. So let's say you just parked your car, there's a bag behind that passenger seat and you're going to reach out behind you and pick that up. Very aggravation. It often results in a tear of the muscle. Also, lifting weights I see people do cleans like this and pick the barbell up. So that's in what we call an empty can position. So when you hold a can and you turn it to empty it, that isolates the most commonly torn muscle, the rotator cuff that we were talking about, the supraspinatus right up here. And when we test for that, we give ourselves you can do it. Now you can just go into empty can position, hold that, give yourself resistance and if you have a lot of pain right here, you might have some at least some tendonitis or even a partial tear of the rotator cuff. About 20% of the population has a tear there just from wearing tear and they don't realize that they have it and a lot of folks are walking around with, you know, an injured tendon that is ready to tear. A weightlifter adds a lot of weight and they're picking up here. That really, really aggravates it.

Speaker 1: 14:00

I had a patient who wasn't getting better. He was a bodybuilder. So wait a minute, what exercises are you doing in the gym? A lot of cleans. He was also holding a dumbbell in an empty can position and doing a lot of repetitions like this and I explained this whole thing to him and he said, wow, okay, I told him. You know what? Just, he didn't believe me at first. I said, just, humor me, stop doing that exercise for two weeks, come back in two weeks. He came back. He was a hundred, was 100 better. I did all the orthopedic testing. He didn't have any problems. I was able to discharge him and and he was a believer that he should avoid those cleans.

Speaker 1: 14:35

What exercises are really good to do is to work the shoulders. So you have the front deltoid, you have the deltoid on the side, you can hold a dumbbell, palm facing you, press it straight toward the ceiling and then now, when it's up palm is away from you, so slowly, this motion that gets the front and the side rows. When you do rows. That works the whole back of the muscles on the back of the shoulder blade, also gets the back of your deltoid, so now you have the whole shoulder. One another exercise that is really difficult on the shoulder and really causes some injuries is military press behind the head and even even in front, like this. This just really aggravates the side of the shoulder, some of those tendons that we talked about. But arnold press arnold schwarzenegger, uh, coined this term and pressing, pressing straight up, just like that, and then doing rows, now you have the whole shoulder. Very efficient, very safe.

Speaker 1: 15:35

Now there's muscles that rotate the ball on the socket. So, holding a band or even laying on your side using dumbbells resistance with bringing your hand into your stomach. Now the ball is rotating inward and now resistance with bringing your hand away from your stomach. This is where in the clinic, we like to use resistive bands for slow, steady work. In the gym I use the vertical pulley system and it'll bring the pulley system to about oh, in line with my stomach and then I'll pull against it. This way, these muscles are strong coming away from my stomach. These muscles are strong Coming away from my stomach. Those muscles are weak. They're supposed to be weak. We don't want to use huge heavy weight. You want lower weight and higher repetitions for these exercises.

Speaker 1: 16:18

When you're reaching and grabbing for something, you want to keep it in close. Another good way to injure your shoulder is to reach out far for something. My bag was on the passenger side floor in my car and I had to get it. I couldn't open the passenger side door. I had to reach.

Speaker 1: 16:34

So when you have to, you're in a situation like that, you lean forward as far as you can and you're still reaching. You can reinforce it with the other hand. So grab the handle of what you're grabbing and then use the other hand. At least use two hands. Okay, if this is let's just say, this is 20 inches away and the bag weighs 10 pounds because of leverage, you have is 10 times 20, 200 inch pounds of force through these muscles. 200 inch pounds of force okay, so that's significant. At least reinforce it and then grab it with both hands, but anytime possible, keep things in front of you and lift in front of you. Keep it in close. There's more to come on the shoulder. This is a very basic yet highly detailed area. I hope you gain some good information. Thank you for liking and subscribing. There's a lot of people with shoulder pain. Please send them this video. Shortly we'll be able to talk on Zoom or on some platform online one-on-one where people can ask me about their problems and hopefully get some answers. Thank you.