Frozen Shoulder is real, and doesn’t only occur in the winter! Generally the condition doesn’t have a definite start point, ie. patients often can’t think of an injury that started the pain. Some warning signs to look for include pain and a loss of motion in multiple directions.
Medically termed adhesive capsulitis, frozen shoulder is a condition that affects the capsule surrounding the shoulder joint. The capsule is a sheath of tissue that maintains fluid within the joint and maintains pressure, ensuring relative stability. Inflammation causes the capsule to become more fibrous and thicken. This causes limitations in range of motion and pain. If your shoulder is feeling stiff and painful, with loss of motion in multiple directions, you may be facing frozen shoulder. Identifying it early is the best
way to help effective progress.
Who gets it?
Although anyone can get this condition for a variety of different reasons, there are a few predisposing factors:
- Most prevalent in women ages 45 to 65
- Diabetes and Thyroid disease
- Previous episode on opposite shoulder
- Immobilization of the shoulder following certain surgeries
- This condition can also develop after a minor shoulder injury
There are 3 overlapping stages of the condition called the freezing; frozen; and thawing phases. Each stage has certain treatments that may be beneficial to help speed recovery, which will be discussed below.
Recovery from the condition generally takes anywhere from 6 months to 2 years, and has the following stages and interventions that can help at each stage:
The Start (months 0-3)
What to expect:
- Pain begins with no initial injury, can be sharp and/or dull in nature
- This is when inflammation occurs, but adhesions haven’t formed
- Pain most notable at endrange movements, but can be present at rest
- Trouble sleeping is common
In this stage, you should see a physical therapist for a few visits to learn exercises to maintain range and slow the loss of motion. You will also be educated on the condition and general progression through the stages.
A few tips:
- Use the shoulder as normally as possible without exacerbating symptoms.
- Intense stretching or manipulation techniques are not advisable in this stage, as they can lead to greater losses in mobility and increases in pain.
- Listen to your body, if your causing a significant increase in pain you’re doing too much
- Keep contact with your PT during this stage; activity or exercise modifications are often needed
Freezing (months 3-9)
What to expect:
- Loss of motion in all directions, with external rotation and raising the arm to the side are usually most affected
- Range of motion becomes progressively worse
- Daily activities (reaching, dressing, bathing, workouts) can become more uncomfortable
- Increased inflammation and blood flow present within tissue
Physical therapy continues to be beneficial in this stage to maintain ROM and function. PT interventions will be tuned to the amount of tissue irritability the patient is experiencing.
A few tips:
- Continue using the shoulder as normally as possible
- Performing range of motion exercises will be helpful in maintaining range
- Listen to your body, if there is an increase in pain with activities and exercising, there may also be an increase in inflammation
- Keep contact with your PT during this stage; activity or exercise modifications are often needed
Frozen (months 9-15)
What to expect:
- Increased fibrosis = increased loss of motion
- Your joint will be much more stiff, but pain will begin subsiding
- Your shoulder is likely to have large range of motion deficits in this stage
You will likely be working with a home program for care at this point. Let your PT know if you have any changes that you have questions during this stage.
A few tips:
- Once again, continue using that shoulder as normally as possible
- Try to avoid movements that are too uncomfortable to complete
Thawing (months 15-24)
What to expect:
- Pain will begin improving, and eventually resolve
- Significant stiffness will remain, but will improve slowly
- Minor range of motion loss may persist after resolution
- Fibrosis of joint capsule, but decreased inflammation
The shoulder will begin During this stage you should begin appointments with your PT for more intensive stretching and manual therapy. Functional strengthening exercises will be used to begin returning the shoulder to normal.
A few tips:
- Intense stretching or manipulation techniques are not advisable in this stage, as they can lead to greater losses in mobility and increases in pain
- Begin a strengthening program that challenges your range of motion as well
- Be sure to work with your PT to develop a comprehensive program to return your shoulder to normal
Treatment of frozen shoulder can be long and arduous, but arming yourself with information can be one of the most effective tools. Make an appointment with your physical therapist or chiropractor to learn more about the condition and how you can manage it effectively. Remember, early intervention and education is essential for recovery.
Bryan Esherick PT, DPT Have questions? Email me at [email protected]
Information adapted from the clinical practice guidelines Shoulder Pain and Mobility Deficits: Adhesive Capsulitis from the JOSPT.
Nine out of 10 Americans suffer from headaches. Some are occasional, some frequent, some are dull and throbbing, and some cause debilitating pain and nausea. Headaches have many causes, or “triggers.” These may include foods, environmental stimuli (noises, lights, stress, etc.) and/or behaviors (insomnia, excessive exercise, blood sugar changes, etc.). About 95 percent of headaches are primary headaches, such as tension, migraine, or cluster headaches. These types of headaches are not caused by disease; the headache itself is the primary concern.
The majority of primary headaches are associated with muscle tension in the neck. Today, Americans engage in more sedentary activities than in the past, and more hours are spent in one fixed position or posture (such as sitting in front of a computer). This can increase joint irritation and muscle tension in the neck, upper back and scalp, causing your head to ache.
What Can You Do to Prevent?
The American Chiropractic Association (ACA) offers the following suggestions to prevent headaches:
- If you spend a large amount of time in one fixed position, such as in front of a computer, on a sewing machine, typing or reading, take a break and stretch every 30 minutes to one hour. The stretches should take your head and neck through a comfortable range of motion.
- Low-impact exercise may help relieve the pain associated with primary headaches. However, if you are prone to dull, throbbing headaches, avoid heavy exercise. Engage in such activities as walking and low-impact aerobics.
- Avoid teeth clenching. The upper teeth should never touch the lowers, except when swallowing. This results in stress at the temporomandibular joints (TMJ) – the two joints that connect your jaw to your skull – leading to TMJ irritation and a form of tension headaches.
- Drink at least eight 8-ounce glasses of water a day to help avoid dehydration, which can lead to headaches.
- And of course make sure you are getting regular check ups with your chiropractor! Research shows that spinal manipulation improves migraine and cervicogenic headaches.(1)
(1) Bryans R, Descarreaux M, Duranleau M, et al. Evidence based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther 2011; 34: 274-89.
CBD oil is gaining in popularity and is showing up everywhere – across the web and on store shelves everywhere. But, many of us are just hearing about it and have some questions – so let’s take a closer look.
CBD stands for cannabidiol – and it is a compound found in both cannabis and cannabis sativa (better known as hemp).
While both plants have hundreds of compounds that may be pharmacologically active, the best known is THC, which has a psychoactive component. However, both plants also contain CBD which also has pharmacological effects but NO psychoactive component. The CBD products at health food stores, grocery stores, and doctor’s offices are sourced from hemp and have no psychoactive properties.
OK, but why is it suddenly all over the place?
There are a number of reasons. It has been found to help with certain seizure disorders and recently the Virginia board of medicine has added it to the legal formula and it can now be prescribed for this purpose. But it is also available over the counter. The recent Farm Bill in 2018 among other things, designated CBD products to be “generally recognized as safe” or GRAS, which means it can be added to food stuffs and sold. For the time being the FDA and DEA have not taken any steps to change that, although they could at any time. Common side effects may include tiredness, diarrhea and changes of appetite/weight.
What can CBD oil do and why would anyone take it? Well in addition to the above mentioned anti seizure properties, there is some limited research that suggests that CBD oil can help people with chronic pain, as well as with sleep, and anxiety. Now the research is far from conclusive and there are many more double blind random control trials that need to be performed before the science and medical communities are going to get behind this being a new cure-all. However, as it has been generally recognized as safe and there are anecdotal reports popping up everywhere with people touting its benefits, people are flocking in droves to try it. We began carrying these products after a few patients requested them and they’ve proven to be very popular with patients for pain relief.
Samuel S. Spillman, DC
Most of us have tweaked our ankle at some point or another. Typically we’re told it’s best to either stay off of it or brace it for a few weeks and it will heal. However, all too often there is an underlying process lurking deep down in the tissues that isn’t going to allow your ligament to heal fully, and leave you predisposed to chronic sprains.
Ankle sprains affect people young and old, in any population, and whether athletic or not. It may happen while playing – or cutting – during a sporting event; when walking on uneven ground or into a small hole in the yard; or you might miss-step off of a sidewalk. Sprains generally affect the outside of the ankle when the ankle rolls, making the anterior talofibular ligament (ATFL) the most commonly injured tendon – which attaches from your outside ankle bone to a bone in your foot.
Once an ankle sprain occurs, there is tissue damage. This can range from a few fibers tearing – causing minor discomfort for a day or two – to a full-blown tear. Unfortunately, with status quo treatments re-sprains are far too common.
We have sensors in all of the muscles, tendons, ligaments – and even in the joint capsules surrounding the joints. Sensors provide our brain with important information about stretch, muscle activation, and joint position. This information allows the brain to form an internal picture of how the joint is doing at that moment. When the initial injury occurs, these sensors get disrupted and stop working properly. When this happens, the brain is unable to create an accurate picture of how the joint is functioning. This altered picture causes the ankle to be less responsive to demands put onto it, preventing your brain to effectively stabilize the ankle. As a result, something simple you may have done thousands of times – like jumping and landing on a volleyball court – may be the cause re-injury. Minor re-sprains can also happen without you knowing. These small injuries usually occur with simple activities like walking in grass. Unfortunately, these minor injuries will continue the cycle of chronic ankle sprains and may delay healing.
So, bracing and rest may not always be the best treatment for ankle sprains.
Of course they have their place with more severe sprains. However, in the case of minor to moderate sprains, braces can actually decrease proprioception and strength, making the ankle more prone to even more sprains! Physical therapy – to build up strength – is often the best treatment for a patient with this condition.
Physical therapy in ankle sprains will help guide you through progressive exercises that will improve ankle muscle strength as well as retrain the joint sensors to perform their job properly. Treatments generally consist of balance and proprioceptive drills on a variety of surfaces and with targeted strengthening exercises. Treatments should be tuned to specific tasks that will be encountered often whether in sports (cutting) or in daily life (walking on uneven surfaces). This is the best route to train the ankle to react to different challenges and prevent chronic sprains.
Bryan Esherick PT, DPT
The official start to Spring is just days away and with it comes spring training. For some of us that means races and triathlons and for others it means golf, baseball, softball and tennis. Whatever your sport or activity, enjoying the warm Spring air and getting your body moving after the long, cold winter may be what you’re looking forward to the most.
Increased activity can bring injury – and while there is no such thing as injury “prevention”, there are measures you can take to reduce your risk of injury. Reducing risk is mostly about planning and timing. You want to give your body ample time to adapt. Your risk of injury goes up when you make sudden large changes in activity or load over a short period of time.
Check out these tips to help you enjoy and injury-free season:
- Don’t increase more than 10% a week. Don’t increase overall work capacity more than 10% whether you are training distance, or weight increase in strength training.
- 4-6 runs a week is optimal, more frequent runs are better than less frequent longer runs.
- Your shorter runs through the week should total more miles than your longest run
- If you have pain during activity, stop and reset, then try again. If you have pain again, you should finish for the day.
- If you have pain after your workout or the next day, don’t increase your miles/weight/repetitions until you are performing that day’s workout WITHOUT symptoms.
- Get enough sleep! If you aren’t getting enough sleep, your risk of injury increases significantly. You should be getting at least 8 hours.
- If you are taking anti-inflammatory medication to avoid/reduce muscle soreness your risk of injury is actually going UP. Inflammation is very necessary for healing and NSAIDs interrupt that process so you sacrifice long term gains as well as increase your risk of a muscle strain or tendinopathy. The soreness you felt is your body’s way of limiting you so it has time to adapt to the forces you are asking it to handle. Listen to your body!
- Your body systems adapt at different rates. Your cardiovascular system may adapt more quickly than your bones, muscles, joints and ligaments. Be willing to change your program to give your body more time to adapt.
- Remember, the point of exercise is to be fun and to keep you out of the doctor’s office, not put you into it!
If you liked this, please feel free to share it. If you’ve got any questions about your spring training plan, feel free to ask questions: [email protected]
Samuel S. Spillman, DC
Have you ever experienced anterior knee pain? The likely answer is yes, and it can be quite debilitating! There are a variety of causes for anterior knee pain including patellar tendinopathy (tendonitis), chondromalacia patella, patellar tracking issues, and more serious injuries like ACL tears. This blog with focus on patellar tendinopathy.
What is Patellar Tendinopathy
So, you may be wondering how this condition starts in the first place. It is usually the result of overloading the tendon before it has time to adapt. By not allowing for a gradual increase in training load, the tendon faces more stress than it is capable of tolerating. Generally it affects the adult population ranging from 16-40 year olds, but can affect anyone if a training schedule is not properly developed. Once the condition has developed, it can take anywhere from 2 weeks to 2 months to fully resolve.
Biological signs of the injury include up regulation of cells that create the tendon, ground substance, nerves, and blood vessels. One hypothesis for why the tendon becomes painful is the in-growth of nerves and blood vessels; picture packing all of these substances into a compact area. The brain and central nervous system may also play a big role in sensitization of the tissue. Pain with this condition like serves more as a “danger signal” to allow the human to know something is happening in that area of the body, and is likely not a signal of tissue damage. Think of this as a warning sign to slow down and let the tendon adapt.
Diagnosis of Patellar Tendinopathy
Functional movements that usually become painful with patellar tendinopathy:
- Going down stairs hurts more than going up
- The deeper the squat, the more the pain
- Sitting for long periods
- Running, jumping, and walking hills hurts
Other hallmark signs of the condition:
- Pain in the front of the knee just below the kneecap
- Pain “came out of nowhere and progressively got worse”
- Recent change in training load
- No catching, locking, or giving-way
Real Life How it Happens
Now that we’ve gone through all the logistics of this condition, lets look at a real life example of how this can happen with running. Picture this: It’s winter, the weather isn’t great for running so you’ve been inside running on a treadmill. You have been consistently running 5 miles with no pain throughout 4x’s a week.
Then BOOM. March hits and its 60 degrees out with the sun shining. New shoes are unboxed and you can’t wait to get outside and hit the pavement. You start running outside with the same mileage, but now you’re running 5-6x’s for 6-7 miles a week because you can’t resist how nice its been outside. One morning you wake up to walk to work or class and you notice that as you’re walking down hill your knee is bothering you a little (nothing serious 1/10 pain). Over the next few days you notice the pain is getting a little worse (2-3/10 pain with stairs, hills, and now its even bothering you a little with running). Now you’re concerned because its starting to affect running.
So let’s break that story down and see how training may have overloaded the tendon before it was able to adapt:
- The obvious, moving from 4x’s a week to 5-6x’s a week and increasing mileage
- Moving from a treadmill which absorbs some shock to pavement
- Flat to hilly terrain
- Even to slightly tilted or cracked sidewalks
- Going from a consistent speed or cadence to one that is likely more varied
- Change in temperature
As you can see, outside of the obvious, there are a lot of other variables that need to be accounted for to allow the tendon to adapt properly. No matter the activity, it is important to allow adaptation to training volume, load, surface, or equipment. The importance of ramping-up training or allowing appropriate time for tissue adaptation can not be overstated. This is why this injury is usually more prevalent at the beginning of a sporting season or training regimen.
As always, better outcomes are seen with more timely interventions versus the wait and see method. Treatment is generally aimed at reducing pain, promoting tissue adaptation and healing, and improving proprioception in the joint and surrounding tissues. Eccentric and heavy slow resistance exercises have been shown to be the most beneficial in treating this condition and some protocols have been established. Since everyone’s tendon quality and pain levels may be different, it’s essential to ensure you are starting at the right level for your level of tissue irritability. If the tendon is stressed too much during recovery, the tendinopathy cycle may repeat itself and may become worse.
Remember, there is no established time frame for recovery, so being patient with recovery is important. The good news is that you can usually continue training during rehab, but it is best to consult your physical therapist about adjusting impact training, training load, or training volume.
Bryan Esherick PT, DPT
As heart health awareness month comes to an end, we want to highlight the wonders of cardiovascular exercise – help clarify exactly what it is – and remind you to keep your heart healthy all year long.
Cardiovascular exercise – or cardio – is defined as any activity that gets your heart rate up. Now, that’s a pretty wide definition which is great because that means you can choose from a ton of different activities – some that you might enjoy more than others, and that means you’ll be more apt to get your body moving more. You could choose anything from: running; dancing; using the elliptical; rock climbing; swinging a kettlebell; playing tennis, basketball, soccer, football; practicing martial arts; taking classes like zumba, kickboxing, or jazzercise… and the list goes on and on – even sex can count! The idea is to choose activities you enjoy, and shift your mind from thinking it needs to be something you don’t like doing.
The benefits are cardio are huge. Most people immediately associate cardio as a weight loss tool, and it’s true that it is a big benefit. But there are so many other wonderful benefits to highlight as well.
Here is a list of health benefits you may have not have associated with cardio:
- MENTAL HEALTH:
- improves mood
- fights depression
- relieves anxiety
- improves cognitive function
- stimulates nerve creation
- boost self esteem
- builds social relationships
- PHYSICAL HEALTH:
- improves cardiovascular health
- lowers risk of all causes of mortality
- decreases risk of heart disease
- improves blood pressure
- lowers cholesterol
- relieves pain as exercise increases pain tolerance
There is also some evidence to suggest that regular exercise effectively slows how quickly our bodies age by helping to repair the little proteins at the end of our DNA strands – called telomeres – which can help to keep us younger and fitter longer. Perhaps we have found the Fountain of Youth after-all!
The secret is to find something you enjoy and like doing, and stick with it. For me, it is martial arts. I’ve trained in it my whole life and get my cardio from Brazilian Jiujitsu and running. Bryan plays hockey and likes to use the rowing machine, while Dongjin plays soccer and Megan opts for aerobic dance. Think about what gets you moving – and of you’re not moving, give us a call and let us help you get started. Who knows, you just might find a new passion or hobby that will help keep you fit for life.
–Sam Spillman, DC
If you’ve ever noticed an ache around the outside of your elbow that just doesn’t seem to go away, you might be experiencing a condition commonly known as tennis elbow. Once it starts, this type of injury can affect your strength and function in your arm. So, if you’re feeling that ache and haven’t done anything about it, now might be the time.
Despite its name, this condition rarely affects tennis players.
It’s most common in sports and occupations that require repetitive movements – think computer work, climbing, heavy labor jobs, etc. Tennis elbow is a form of a tendinopathy – affecting the tendons of the forearm muscles – classically called tendonitis. The tendons undergo a degenerative process as a result of highly repetitive stresses. This process causes: increased blood to flow to the area; collagen creating cells; and ground substance. This cascade of changes can lead to pain and discomfort in the area – as well as poorly formed tendon structure which is then vulnerable to further injury.
Due to the nature of the injury, and the general inability to stop activities that aggravate the condition, it can take from a few months to up to two years for the tendon to fully recover and for pain to subside. It is possible for the condition to subside on its own, but there are steps you can take to decrease the duration of the symptoms.
Treatments for this condition vary greatly from surgery at the most extreme end, and to wait-and-see on the other, with everything in between. At Balanced we focus on rehabilitating the tendon through gradual loading of the tissue to reorganize collagen; and soft tissue work to relax overactive muscles; and education to empower our patients to heal quicker. We generally recommend avoiding bracing, cortisone shots, and surgery. By optimizing the environment for the tissue to heal, our patients often obtain quicker results and are able to return to normal activity and reach their goals within a more predictable time frame.
Bryan Esherick PT,DPT
A good recipe can help you cook your way to one’s heart. Someone also once told me that the key to a happy life, is a happy wife. So, for this Valentine’s Day, I decided to put the two together and share this idea for your special holiday planning this week. h/t to Mark Bittman of the NYT for this inspired meal.
Black miso cod, miso soup, salad, rice, and chocolate ganache covered strawberries for the ever-coveted dessert.
This is a great recipe for someone who is not an experienced hand in the kitchen. It’s amazing, and tastes like the most complicated and delicate dish ever prepared. But, as it turns out, is really easy!
- Combine 1 cup of miso paste with 1/2 cup of sugar and 1/2 cup of sake and simmer in a small sauce pain. You can bring it to a boil but then let it cool.
- Lay out your Chilean Sea Bass or Black Cod (they are very similar) in 6-8oz pieces.
- Fire up your broiler. Place the rack 4-6 inches from the top.
- Generously coat the fish in the miso sauce.
- Broil until done, typically about 5 minutes per 1/2″ of thickness.
- Remove from the oven, plate and enjoy!
Pair it with some miso soup (also easy to make):
- Bring 4 cups of water to a boil with 1 tablespoon of dashi.
- Add 1/3 cup of red or white miso paste and stir.
- Add 6-8 oz of shiitake mushrooms and you’ve got a simple and flavorful miso soup in about 10 minutes.
I’d consider a simple tossed salad with Japanese style ginger dressing.
Lastly no Japanese meal is complete without a bowl of steamed rice! Any Japanese short grain will do, I usually choose Calrose.
Finish it off with chocolate covered strawberries, with fresh ganache:
- Destem and wash large, fresh strawberries
- Melt 8 oz of dark chocolate chips in a small pan inside of a larger one filled with water
- Slowly and steadily stir in ½ cup of heavy cream until fully mixed.
- Dip the strawberries and leave them to cool on some wax paper in the refrigerator.
*If you don’t mind a little corn syrup you could add a splash to the chocolate mixture (just a splash) and it will give the ganache a nice shine. But this is optional. Make as many as you’ll think you’ll eat.
Voila – simple to make, decadent and romantic Valentine’s dinner!
– Sam Spillman, DC
The knee joint is the most vulnerable and most common snow sport related injury. The good news is there are steps you can take to condition and prepare your body for winter sports such as skiing.
Things to do in preparation for your ski trip:
- Core and lower extremity exercises (listed below)
- Training your cardiovascular fitness- many injuries occur as a result of fatigue
- Proper equipment that is appropriate for your height and skill level
- Take a skiing technique class before hitting the slopes
Preventing Injury on the slopes:
- First off warm up your body before hitting the slopes each day
- Proper technique: Hands and weight forward, legs parallel and hips, knees and ankles flexed equally
- Stay on trails that are marked for skiing safely
The following are exercises should be preformed several weeks before you plan to ski. All of the exercises should be attempted for 1 minute and increase the time as you improve.
Standing on one leg reach the other leg toward an imaginary clock face. Repeat on other side.
With both feet close together bend your knees and jump side to side while maintaining a straight spine and a flat back as well as even weight in both feet.
Start from a squat position with feet close together jump from diagonal to diagonal landing on the balls of the feet.
Side to side skaters
Stand on one leg and take a large step to the with the other leg and then take another large step back to where you were. Make sure your pelvis stays level and your knee does not buckle inward.
Check out the full video for these fun and helpful exercises!