Anatomy of Shoulder Injury

There’s no doubt about it – the shoulder complex is one of the most commonly problematic areas on the body and can be frequently injured. But before we can talk about what can go wrong in this complex part of the body, we need to quickly review some anatomy and functionality.

The fist thing to note is that the shoulder complex is actually two articulations – the scapulothoracic ‘joint’ (really the muscular articulation of the scapula or shoulder blade on the chest) and the glenohumeral (GH) joint (the true shoulder joint). Let’s look first at the scapulothoracic joint and it’s anatomy.

The Scapulothoracic Joint

So, as we can see above, the scapulothoracic joint is only connected to the skeleton via the clavicle. This creates joints at the sternum, the sternoclavicular joint (SC) and at the scapula (at a point called the acromion), the acromioclavicular joint (AC), allowing the clavicle to act as a strut for the shoulder complex and to provide some additional stability and force transmission to the skeleton.

Below we can see the muscles which act upon the scapulothoracic joint. Most of these are familiar to those of us who train in the gym, as these are the ‘shoulder muscles’ that are commonly trained in weight training, and also those that first pop into our mind when most of us think of ‘shoulder muscles’. It is important to note that these muscles, however, do not actually directly act on the shoulder joint – rather they control and stabilise the scapula.

So, what is the purpose of having this joint?  While there is a range of localised movements we can engage with the scapulothoracic joint, its most important function is to create and stabilise complex shoulder movements alongside the GH joint.  We could think of this a method of actively extending the range of shoulder motion and increasing the power we can put through the shoulder joint through elevation, depression, protraction, retraction and upward/downward rotation.

You’ll notice that for these movements to occur, certain ranges of movement need to be available at both the AC and SC joints. Normal ranges of motion are as follows:

SC: Elevation: 48 degrees; Depression: 15 degrees; Protraction: 15-20 degrees; Retraction: 20-30 degrees

AC: Sufficient hinge and glide to allow for normal shoulder movement

The Glenohumeral (GH) Joint

Next we have the glenohumeral joint (GH), this is the ball and socket joint we all think of when we think of the shoulder. While it is technically a ball and socket joint, what makes the GH stand out is the shallowness of the socket which allows for a large range of motion. As the joint lacks bony stability, it relies upon dynamic stabilising in the form of the shoulder cuff muscles (the tendons of which also form the shoulder joint) and the tendons of biceps and triceps.

In addition to providing stability, the shoulder cuff muscles also produce a large proportion of the shoulder’s functional range of motion. The GH joint’s range of motion is illustrated below:

The Total Picture

So, as we can see the shoulder complex is a complicated and dynamic area with many inter-related systems of movement and stability that must work together not only in strength, but in timing of their contraction while producing movement if we want to have a stable and healthy shoulder. The diagram below nicely illustrates how much each joint contributes to the simple task of a vertical press.

And of course, because the GH (the true shoulder joint) is a part of the scapula (which itself is capable of a large range of motion), how we stabilise the scapula has a tremendous impact on the GH joint’s mobility, stability and movement. Part D in the figure below illustrates this very nicely. We can see that a the scapula is protracted, retracted or winged, the orientation of the GH joint is altered significantly. This is an important concept for dealing with shoulder problems, as we will see.

Next: Postural Strain/Fatigue in the Shoulders

Autumn Runner Prehab

There’s no doubt about it, Autumn’s arrived here with a damp squelch! But if the thought of muddy trails puts you off, check out my 3 minute prehab guaranteed to get you loving the mud.   https://quik.gopro.com/v/GIrF74bXcU/

What can I do about my pain?

We hear it all the time, ‘I bent over to pick up (insert item here) and my back just went.’  How can something seemingly so innocuous cause so much pain?  Is the back so fragile?  Is my back ‘weak’?

The first thing to remember with ongoing back or neck pain is that, barring traumatic injury, there is usually little cause and effect in terms of the onset of the pain.  Rather, it is a combination of factors that all happen to peak at the right time and place to cause those symptoms.

So, what are those factors?  There are usually 3 main elements, each working to a greater or lesser extent:

1. Poor movement – By this I mean either lack of overall movement for those of us who are sedentary all day, or too much of a particular movement for those of us in manual work.
2. Poor function – This is the way we use the body, whether it be posturally or in exercises/manual tasks.  This is a dynamic concept – good functional use for one activity will probably differ from another, although there are common themes which carry across.
3. Emotional or physical stress – The perennial favourite.  When we experience emotional stress, we tend to tense up – and tense movements/postures are rarely good ones.  Physical stress may contribute to tissue overload.  Either way, stress can amplify poor useage and loading in the body.

Take this scenario:

Joe Blogs works in an office 9 hours a day, uses two screens and eats lunch at his desk (and rarely moves from his desk).  He drives to and from work and then relaxes watching his favourite telly shows on the sofa.  Add to that, Joe is also overweight and in a stressful job.  Joe has chronic intermittent back pain… let’s see why.

• How much movement is Joe getting?  He is just going from one static posture to another.  You could say his movement is nearly nil… why is that important?  Any posture needs muscle activity to support it (poor postures even more so… but more on that in another post).  So, think of lifting a tin of beans – easy, right?  Now hold that tin at chest height for a few hours – still in doubt about the effect of constant, sustained muscle activity?
• Is it likely that Joe is adopting an efficient posture?  Possible, but probably not likely – let’s face it, human nature is to slouch and slump when sat all day unless we are mindfully aware of correcting our posture.  So, his function of the muscles and spinal column is probably poor.
• Joe is overweight – think that is physical stress on the body?  You betcha.  Studies show time and again that one of the most sure-fire ways to decrease any nusclo-skeletal pain is to lose weight.  He also has emotional stress at work, which is going to likeley increase his overall tension, especially across the neck and shoulder areas.

OK, so looks like bad news right?

Actually – there is a load that Joe could do to improve his lot, even without seeking outside advice. So, if you’re in pain and see some of the above elements in yourself, what can you do?

• Move more!  Yes, just taking short, frequent breaks can be a great start.  Set your timer for each 30 minutes, get up and make a cup of tea, drink of water, whatever just to get a break from your posture (lower that tin of beans!).  Even better, find ways to sneak movement into your day – take walking meetings, walk or cycle into work (even part of the way), take stairs instead of lifts.  Easy.
• Do something to challenge your movement – take up a sport, or dance classes, gardening, water polo, yoga, pilates or just walking the dog.  Regulalry take your body through lots of different planes of movement doing something you enjoy.
• If you have a few extra pounds, try to shed a few – you’ll feel a tremendous benefit in pain relief.
• Stressed?  Try some options to relax like meditation, mindfulness training or yoga.

Remember, you don’t need to get all the elements perfect – just try to keep them from running out of control and you’ll notice an improvement in your symptoms.

Sole Support

To orthose or not to orthose – that is the eternal question… Being of a minimalist persuasion I always prefer to work with my clients to maximise their intrinsic control and strength to solve foot loading problems (and I will post a mini-series next of some common quick fixes), but there are time when an orthotic (custom insoles) are just the trick. So – when are those times?

Loss of Function

Many things can cause some degree of altered or lost funtion in the ankle and foot… this may be wear and tear (osetoarthritis), injury or congenital weakness (fallen arches).

Regardless of the cause, there will be some alteration in what the foot is capable of handling in terms of force and stability. Sometimes this altered loading can manifest as back pain, or pain in the hip, knee and foot. Often when starting a new activity or training for a certain sport.

This isn’t to say that an orthotic is always needed, in fact most people cope perfectly well without any help – but may only need the correction while doing sport or certain jobs.

A ‘Quick Fix’

Ok, so it’s not the ideal situation – but there are times that as a clinician where we need to break the cycle of pain by forcing a change in function. Orthotics are great at this – and, provided the foot was contributing to the pain, can really aid a speedy recovery.

Sometimes as well, it can help those patients who have difficulty adhering to rehab exercises experience relief and support a new, better function in the leg and foot. Not ideal, as the patient is’nt active in this change, but it gets the job done.

To Speed Along

One that I’m really in favour of, especially for athletes who need to change foot loading or gait. Along with the active exercises orthotics can be customised and made to support this new, desired loading and foot mechanics. This therefore keeps the process going both in a passive (orthotic in shoe) and active (rehab exercises) way … with the aim of discarding the orthotic once the treatment goal is acheived.

So – although they’re not a panacea (no one thing is) I think it’s a real mistake to not use them as a tool. I know in my own experience that the more ways I can get my patients engaging actively in the rehab process the better the outcomes will be…. and often these are powerful tools to help acheive that.

Time Out For Injury

It’s about this time of year that I start to see more and more victims of overuse and overtraining in the clinic.  So- if you’ve got some niggling pains creeping in, what should you do?

It’s always best to have a quick think about the causes behind injury – and in cases of overuse injury I think there are likely three main reasons for the timing:

1) competiions and races are abundant and hard to resist for the competitive mindset (more competing = more strain)

2) amatuer athletes have a strong tendency to over cook their training programmes, and this is about the time when the body will break with that extra stress

3) being summer, we tendto be generally more active and often doing daft things with the kids and friends, and pick up acute strains.

So, what can you do about the situation?  Well, the first thing is to adjust your goals and plan your return to sport based upon the degree of injury.  For many simple muscle strains 7-10 days should see you feeling somewhat better.  Assuming all is well, aim to start back in gently to your sport – keeping 1-2 weeks free for this ‘settling in’ where your goal is purely to accustom your body to the strains intrinsic to your sport.  Following this, usually starting back in with a 20% drop in your pre-injury training load is a sensible approach and a slow re-build from there.

Being injured can be a painful lesson in trianing programme design, but here’s a few general tips that may help:

1) Keep in mind your goal behind each session… don’t just run/train yur uts out every run/session, or your body will break down again.  Is your goal to build strength? CV endurance? race pacing?  Each will have its own guidlines for safely and efficiently ensuring your goal is met – these are beyond the scope of this brief post, but an example might be for a runner:

Overall Goal: 45 min 10k

• CV endurance – run at 8.30 – 9 min/mile (bulk of mileage)
• Strength runs – Hill training or intervals (1x per week 8 weeks out from race)
• Pacing runs – run at race pace intervals (800m or mile) (1x each 2 weeks 8 weeks out from race)

So- if you were running 30-40 miles per week, the vast majority might be at a conversational CV building pace, with one day or two if later in the cycle of hard efforts… so if your training consists of five all-out efforts, you’re in all probability doing way too much.

2)  Remeber to alternate tough with easy days.  As with above, not every day needs to be a max effort.  Recovery efforts, cross training or alternate CV exercise are ideal for mixing things up as well, and get your body using some different muscle groups – it doesn’t replace sport-sepecific training, but by mixing things up you can train harder with a lower risk of repetitive strain or sport-specific overuse injury – in theory.

3)  Know the signs of overtraining!  These aren’t just physical pains.  If you’re feeling overly run-down, catching every cold going or have a raised morning resting pulse rate 10bpm or more over your average resting rate, you’re body’s feeling the stress- so it’s time to back off and let your body recover properly.  Do it now and you’ll help avoid being off for weeks nursing a muscle injury or the ‘flu.

 

Just a Little Strain?

I thought I’d shoot off a quick piece about this as I’ve had a few clients come in with what they thought was a simple tendon or joint strain, but has actually proved to be a small fracture. It’s actually quite common, particularly in the lower leg and doesn’t necessarily have to be from massive trauma.
Firstly, what is a ‘normal’ strain/sprain? Here we’re talking about joints that get rapidly stretched beyond where their normal anatomical position – think of turning your ankle for example. The joint capsule and surrounding area are full of nerve endings and it can be massively painful, but the actual degree of damage can vary widely.

So- what are the common things to look for in a strain/sprain? In short, all your typical signs of inflammation : swelling, redness, bruising, heat, and pain. Normally the pain here correlates to a lack of movement or stiffness in the joint as well (joint movement requires the joint capsule to shift and squeeze so if there’s inflammation and injury, your body won’t like this and will send out pain signals).

These simple strains/sprains also should gradually get better over a week or two as you re-mobilise, and rehabilitative exercise can be immensely helpful in restoring healthy movement and preventing recurrence.

So – what about those injuries that are still immensely painful weeks after the initial event? Here’s some common things to look out for that might warrant to you check back with your GP for an x-ray in case of a stress or hairline fracture:

1) Pain which doesn’t improve with ‘active rest’ – ie, even your daily activities (non-sport) are very difficult or painful. Basically if it it doesn’t follow the pattern of a simple strain above.

2) A deep, or ‘bony’ ache in an area away from a major joint or muscle.

3) Pain on compression or standing but not un-weighted movement (sometimes severe).

4) Pain which is unrelated to muscle contractions or joint movement.

But- wait! Perhaps you have an x-ray from A&E on the day of your injury and all was clear? Bad news is that often stress or hairline fractures are very hard to pick up when fresh, and medics have a much better chance of seeing them once they start to repair (the new bone shows up a bit whiter).

Ok, but what is a stress or hairline fracture? It’s a tiny split in the bone matrix, but not enough to cause a full-on broken bone. Sometimes these occur due to too much compression force (metatarsal heads are very common for runners) or there can be a tiny crack where a tendon insters onto the bone. Either way, it needn’t be a huge event – often just catching the foot or body part in the wrong position at the wrong time is enough.

Remember – if in doubt, get it checked out!

Fairford 10k

So – after the weeks of training, the big day had finally arrived.  In the end I opted for my Luna sandals on the run, purely for practicality (the route was through country lanes and I wasn’t 100% sure of the surface underfoot that I would encounter) however, these give the best approximation of barefoot running of any shoe I’ve tried so I figured it was still in keeping with the spirit.

My goal was a sub 50 minute 10k (which I was confident of from my training runs), and my ultimate, optimistic goal was a 48 minute 10k.  Happily, I comfortably broke my optimistic goal and posted a 47.40!

My race strategy paid off – setting realistic goals and not letting myself get caught up in someone else’s race.  I think I did a reasonable job of pacing too – purely by RPE (perceived exertion) though… and I finished feeling confident and strong.

I think on balance I enjoyed my barefoot training, but it did throw up soome problems in terms of practicality.  There are some days when I missed just being caught up in the moment and enjoying the freedom of running – and not having to be distracted by grumbling soles or rubbish pavements – I’ve come to loathe all the miles of acid-rain etched asphalt footpath around Cheltenham.  But I got great corrective feedback to work on my form.

So- what next?  First, I think on balance I prefer running in my Lunas – it’s that ieal balance between maximising my enjoyment and getting a barefoot experience… and not having to stress about the surface my runs take me over.  Event-wise, I think I’ll build-up again and booked myself onto the Malmesbury 10k in September – and my goal is to break the 45 min 10k barrier!

Bare Experiment Week 6

So this week I decided to have a nice race-prep long run to check that my plan was still realistic and achievable. On my long run (6.5 miles) I thought I’d run a fairly flat-out tempo to push myself and emulate the mistakes I usually make in racing (i.e. starting out too fast and overcooking it)- to see if my goal time is still achievable when I’ve blown myself out a bit.
I’m happy to say that, even with some really harsh pavement underfoot and setting out too fast, I managed to do every mile sub 8 min/mile pace- so I’m feeling pretty confident in meeting my realistic goal of 50 min for 10k and highly likely I can get my desired goal of 48 min 10k! I am, however, feeling it this week in training as it’s taken me much longer to recover from a max effort-style run than it has for the paced effort runs I’ve been doing. So, I thought I’d take a moment to talk about approaches to training and how they impact both our performance and injury.
Most of us amateur athlete- especially men- tend to feel as if we haven’t trained properly unless we leave the scene of training crawling on our hands and knees and barely able to speak. While I’m a big advocate of giving yourself a good beasting every now and again, doing this every workout can have some detrimental effects.
1) Broadly speaking, training of any sort works best if done with specific intent. With running for instance, a session designed to target aerobic fitness will require a different pace and approach than that designed to build speed/strength. If every session is run a max effort, middle distance, there’s no specificity and you could be missing big gains from targeted sessions.
2) The harder the workout, the more recovery the body needs. This is especially true if you’re just starting out or getting back into shape. Long, gruelling speed/strength sessions will come, but keep things in proportion to your overall mileage to begin with (so, perhaps if your long run is 6 miles, use 6 hill reps or 6 400’s etc.)- and schedule something less leg-intensive the following day to aid recovery, and space it widely from your next speed session. If you allow your body time to rest and recover, you’ll find that you can approach each session with good, strong legs and form- and get more out of it!

3) Constantly asking your body for the max limit puts loads of strain on the tissues of the body – and combined with inadequate recovery time is a perfect storm for injury. Many of the runners and triathletes I see in my clinic with injuries that put them out of training for weeks or months have one thing in common – training overload. Especially after they had already noticed and injury brewing! This is partly, I think, because of a lack of pacing, or being unwilling to knock training down until the body fully recovers. This is, in my experience, always a poor trade-off: you may just scratch through your event nursing an injury, but it will be a poor shadow of what you should’ve posted- and you’ll likely be out of action for much longer rehabilitating that injury.
4) Pacing is a good thing! Being more disciplined on training runs means that you’ll be more likely to race strategically, and meet your goals rather than over-cooking yourself and finishing poorly. If you train in your mile, 5k, 10k, half marathon, etc. paces then come race day you have a really good idea of what time you will achieve- and that’s good for your own psychology.
5) Lastly, by being more specific you can learn to enjoy running more- and more fully! You can savour the slower-paced aerobic runs and beat yourself up on the speed work… and enjoy the fact you’re getting faster and racing without injury.

This week in Training:
The Goal: 50 min 10k (or less) barefoot – 8 min/mile pace
Long Run: 6.5 miles (sub 8.0 min/mile pace)
Temp Run: 3 miles (about 7.5 min/mile pace)
Cross Training: 1 day bodyweight HIT, 1 day 50 min cycle
Speed: 6 x Hills

Bare Experiment Week 5

Finishing the week with a 10k just below 50 min (49.15) has a nice feel. Although pretty confident that my goal is achievable, I will schedule in for next week a mock race-pace to know for sure what my body will do on the day.
One thing I did cheat a bit on this week was the use of my huararaches (running sandals) for my sprint work, as it was a very wet day out training and I usually find this is hard on the feet when doing fast work. Even though your soles get tougher running barefoot, they still tend to get soft and wrinkly when bathed in water. Consequently, I ran at a faster pace than my usual, by about 20sec per 400- and it felt pretty good. However, the following day, my feet told me about it… I’d increased my pace too quickly and they ached pretty much every step the following day (but didn’t last longer than that thankfully).
It was a powerful reminder of how potentially damaging running in a minimalist shoe can be- not from the shoe itself, mind… they are great tools and I love mine. The danger comes from the fact that they allow us to put stresses and forces through our feet before they are ready and adapted for them. This is a huge point for anyone interested in minimalist running!
Clients have asked me again and again about which shoes to transition into minimalist running with. But, as with most things, the answer depends on your end goal. Do you just want to dip your toes in to the pool and get some better ground feel, maybe less heel drop? Or do you crave a real, pure minimalist feel?
In my opinion the minimalist trend has produced some fantastic mainstream footwear which gives loads of feel but gives you all the normal protection you’d normally have in your running shoe. This means you can better work on your form etc. without sacrificing training load or times as much. Because they cushion and protect, it means that the foot isn’t subject to the same loading forces as something nearer to barefoot and therefore you’re less likely to get a TMTS (Too Much, Too Soon) injury using them.
However, if you really crave the pure, minimalist footwear- I would say this: train your body barefoot until you can run moderate distances, moderately fast, even if your goal is not barefoot running– and only then select a pure minimalist shoe (like Vibram Fivefingers or VivoBarefoot) to train and race in.
Why? The reason is simple- your bare feet will only take so much abuse before you will force yourself to stop… usually this is from superficial abuse like ‘hotspots’ or sole tenderness. Bare feet force you to train in small increments back to a racing fitness. The body needs this time and stimulus to strengthen the tissues in the feet and calf, so that when you get back to posting your old times (and beyond) you can do so injury free.

If you protect your feet from the superficial abuse with a hard-core minimalist shoe, you lose that valuable self-check in the early stages. All that stress and force is still going into the feet, but the internal wear-and-tear doesn’t usually make itself felt until after the session or the following day- too late. And this is because we forget how much extra force goes through our feet for every 15 or 20 sec per 400, for example… it seems like it’s a bit harder for us physically, but it’s exponentially harder work for the foot.
If you want to go ultra-minimalist – it’s far better to go barefoot first!

This week in Training:
The Goal: 50 min 10k (or less) barefoot – 8 min/mile pace
Long Run: 10k (about 8.0 min/mile pace)
Temp Run: 2.50 miles (about 7.5 min/mile pace)
Cross Training: 1 day bodyweight HIT, 1 day 50 min cycle
Speed: 5 x 400s (7min/mile pace or less)

Science-Based Bodywork

On my website you may have noticed that I promote a ‘scientific approach to osteopathic treatments’. But you may rightly ask- what do I mean by that? And why is this distinction necessary? First off, maybe it’s easier to explain what a rational, scientific approach means in terms of exercise and manual therapies in general – and how things get mis-interpreted by practitioners and clients alike.
Science is a system of statements derived from observation and controlled by experimental verification. The first bit is easy- we all observe things and create stories or ways of explaining the world, way back to the invention of religion as a way of explaining the inexplicable. Where this becomes tricky is that little bit on the end where we also have to provide experimental verification of the model we propose- it isn’t enough to say that, ‘I have developed a model to explain the world and people tell me it works’.
And this is because as people we are notoriously bad witnesses. We are prone to loads of biases, and this is no doubt very good for us as a species because these allow us to build social frameworks and evaluate threats and search for food effectively and quickly. But this is not so good if we want to understand the world in an unbiased way. For this we need to devise a way to test our preconceptions and evaluate them to exclude random events and bias. This is why experimental verification and statistical analysis is so vital- without it, we have no way of proving that theory A is wrong and theory B is correct or visa versa.
Such a need is easy to understand with physical things like aerodynamics, engineering or physics… because the thing we are evaluating itself has no bias (an wing shape either flies or it doesn’t – and you can build a mathematical model to quantify its effectiveness). But the problem becomes huge when confronted with evaluating people’s reactions to exercise or manual treatments whose aim is pain reduction (as much a people have tried, there just hasn’t been mooted a scientifically plausible model of how systemic disease is treated by exercise or manual therapies).
Pain is a highly subjective thing and there are ways of evaluating it properly, but like most things involving humans and subjective symptoms (unlike objective markers like wound healing times or arterial flow etc, say) it becomes hugely important that we ask the right question and are looking at the right potential effect- which isn’t as easy as it sounds. However, because of this innate ‘wooliness’ it’s easy for people to do bad research and poor analysis resulting in apparent ‘scientific support’ for a claim that doesn’t stand up to even a cursory critical analysis.
There is, thankfully, a drive to build a proper, externally verified research base for manual and exercise treatment methods – but it’s been woefully slow on the manual therapy side. So – in a field of little quality experimental evidence, should we practice any sort of voodoo and submit to the gurus? Thankfully, we have something rational we can do- work from a model which holds scientific and rational water. This means approaching the body from a biomechanical perspective and being critical of your own work – testing an objective marker (or even a subjective one like pain) before and after a treatment.
This also means not misleading your clients with magical mumbo-jumbo. If someone says they’re working with your ‘energy’ they’re talking bollocks. If someone says they’re going to treat your asthma by holding your head – they’d better have some convincing evidence to prove it… I’d be willing to bet they couldn’t offer you a persuasive argument of how the proposed treatment actually would work. Some things feel nice, relaxing or soothing to have done – and this is absolutely fine… and of real value. But, however nice having your acupressure points done or reflexology done – if you’re getting treatment for something other than musculo-skeletal pain or stress, I’m afraid no amount of wishing will make it work. And these methods can be used and explained in a scientific way (and still work when used this way) – we don’t need this metaphysical junk.
Lastly, it means being prepared to change how you practice based upon the most up-to date research. Even conducting self-audits for effectiveness and changing your approach based on your findings. Otherwise, what you are operating on is faith. You are practising a religion or mysticism, which offers no verification of success or room for professional growth.
So- in practice, what does this mean? Well – firstly an accurate diagnosis (recognising that this is something you can, or can’t, treat and testing this hypothesis) and agreed goals with the client to monitor progress. Second, an application of techniques which are appropriate, safe, and based upon scientific evidence or at least a model which is rational and scientific. Of particular importance here is addressing the fact that manual therapy alone can offer relief of symptoms, but almost always is best accompanied by directed exercise – this exercise is what re-trains proper function into the body and provides long-term relief of symptoms.