Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (20 page)

Becky is a talented seventeen-year-old softball pitcher who plays in one of the highly competitive girls fast-pitch leagues in New Jersey. Last year, her season looked to be over before it had begun. Every time she pitched with her usual velocity, she’d be stopped by pain in her throwing arm. Her orthopedist didn’t see any muscle tears on the MRI, only minor inflammation, so he told her to take some time off and sent her to PT to work on muscle strength and conditioning. When she returned to the mound, the pain returned to the shoulder. A couple of rounds of anti-inflammatory injections had only a minor effect. When Dr. DeStefano treated her, he found that a number of her shoulder muscles were misfiring. The big offenders were the rotator-cuff muscles, especially the subscapularis. Traumatized by the repeated force of Becky’s pitching motion, it was shortened, tight, and injured, throwing off the movement of the humeral head in the joint and inflaming the entire area. After Dr. DeStefano manually broke up the muscle tightness and the inflammation subsided, she was ready for physical therapy to strengthen her shoulder. Becky was back on her softball team in weeks.

The vulnerable shoulder has a hard time with sports. The pitching motion is particularly tough. The rotator-cuff muscles have to fire strongly, especially to deaccelerate the arm after the pitch is thrown.

The supraspinatus is the “star” of the rotator-cuff group and, being relatively easy to get at on top of the shoulder blade, it gets its share of therapeutic attention. But sometimes the subscapularis is the hidden villain. Located on the underside of
the shoulder blade next to the rib cage, when it tightens up, it rotates the arm inwardly. Becky was fighting against her damaged subscapularis every time she went into her pitching motion.

Shoulder Instability

Laura, a teenager from Sheepshead Bay, Brooklyn, New York, swims on the U.S. national team. She was diagnosed with a lax shoulder capsule, fairly common in swimmers. The ligaments that form the capsule that holds the shoulder joint in place were naturally loose. These hypermobile joints can be an advantage in competitive swimming—Michael Phelps is a great example —but for a lot of swimmers they can lead to muscle pain, even shoulder subluxations (partial dislocations). Laura’s rotator-cuff muscles were having to overwork to keep the joint in place, and her subscapularis muscle in particular was tight and fatigued. Dr. DeStefano treated her manually to reset the balance of the rotator-cuff muscle group. The tighter muscles were loosened manually. The muscles that had lost strength from being underused were built up in physical therapy.

Like a lot of athletes, when Laura doesn’t feel right, she wants to do something to get at the problem. When she felt tightness in her shoulder muscles, she would stretch the area nonstop, further loosening the shoulder capsule, which was the cause of the muscle tightness in the first place. She incessantly rubbed the area as well, and her unskilled direct pressure became another source of muscular irritation. We gave her some stretches and strength exercises that targeted the correct muscles (see the program of self-treatment and stretches at the end of the chapter), and she happily returned to the national swim team.

Muscle or Joint?

Rotator-Cuff Tendinitis/Partial Tears

For most of us, rotator-cuff injury is a story of slow decline. With age, the tendons lose their suppleness. They become irritated rubbing against the bony underside of the shoulder blade when the arm lifts up into the overhead position. Painful tendinitis sets in and the rotator-cuff muscles begin to shut down, throwing off the motion of the shoulder ball in the socket. The ball can ride too high, pushing the cuff tendons against the tip of the shoulder blade (impingement), compounding
the damage. (The bony tip itself may be shaped in such way as to gouge the cuff tendons.) Usually the best way to stop the downward spiral is manual therapy to address the muscles and, when the inflammation and irritation have calmed down, physical therapy to build up strength in the rotator cuff and surrounding muscles. Otherwise, tendinitis can so weaken the tissue, the tendon tears, partially or completely. Partial tears can heal by themselves, “full thickness” tears cannot and often require surgery.

Frozen Shoulder (Adhesive Capsulitis)

Busy with family and volunteer work, Joan had let her tennis game go for the past few years. When she moved to a new neighborhood and discovered the nice public courts, she threw herself into a regular schedule of twice-a-week tennis, good exercise for a woman now in her early fifties. She didn’t make any extra time for conditioning or stretching, but that didn’t seem to affect her game. Several weeks into her new routine she began waking up at night with a dull ache in her shoulder. She had to experiment with comfortable positions just to get back to sleep. The pain became sharper, disturbing her days as well as her nights, and she was losing range of motion in her shoulder. Putting a coat on became difficult, so you can guess what playing tennis felt like. Her orthopedist diagnosed “frozen shoulder”—the fibrocartilage capsule that encases the shoulder joint was shrinking and tightening, causing the pain and restricted movement. He explained that surgery is rarely the best option and sent her to a physical therapist to strengthen the shoulder. Fortunately the therapist was well versed in manual techniques. Before launching into the strengthening exercises that would overload the damaged shoulder muscles, she worked to release tight muscles around the capsule and, by pressing directly on the capsule, broke up some of the scar tissue that gummed up the works. Adhesive capsulitis is a stubborn condition; it took several months of treatment before Joan’s frozen shoulder was completely “thawed” and she was back on the courts. On this second go-round, for every hour on the court, she spent an hour in the gym, stretching and strengthening her body to handle the demands of her sport.

Why the shoulder capsule should behave this way—the tissues begin to stick together and stick to the muscles that pass over them—is something of a medical mystery. Without treatment to speed healing, the capsule is likely to “freeze” for the better part of a year, then gradually “thaw” for several years as the pain subsides
and most, but not all, of the lost range of motion returns. Frozen shoulder mostly affects women in their middle decades, which suggests that declining sex hormones play a role. Pushing an out-of-shape shoulder through a lot of overhead movement seems to be one way to set yourself up for the condition. A course of anti-inflammatory injections may be helpful.

The surgical solution is to cut the scar tissue in the capsule, then, with the patient under anesthesia, force the arm through its full range of motion. It works, but as long as the manual approach yields results, there’s no reason to subject the patient to the risk of general anesthesia.

Joint/Orthopedic

Rotator-Cuff Tears (Full-Thickness Tears)

A recent patient of Dr. Kelly’s was a fireman who, when asleep on a beach, had an off-roading truck run over his shoulder. Dr. Kelly repaired the huge tear in the tendon of the supraspinatus muscle, and the man went back to his activities.

There are no hard-and-fast rules about when to surgically repair the rotator cuff. Dr. Kelly was the lead author of a 1995 study that found that some people with serious cuff tears could still lift their arms over their head. Their strong muscles adequately compensated for the structural damage. Remember, just because something is broken doesn’t necessarily mean it needs to be fixed!

For people in their eighties or nineties, it may be easier and wiser to adapt to physical limitations—don’t put the cereal on the top shelf—than to deal with the rigors of surgery and rehab. For a guy in his thirties who installs Sheetrock for a living, a fully operational shoulder, or close to it, is his paycheck, and surgery is usually a given. The younger the patient and the better overall condition of the tendon, the better the odds for a successful surgery and a full recovery.

Shoulder Separation

As a lot of football and hockey players know firsthand, a sharp blow to the shoulder can sprain and even rupture the acromioclavicular (AC) ligament, which binds the collarbone (clavicle) to the broad tip of the shoulder blade (acromion process). In plain English, a shoulder separation. Most cases, with the help of RICE, heal on their own. The most serious ruptures may require surgical reconstruction of the AC
joint to allow the arm to be lifted normally above the head, but surgery on this joint is not common.

Shoulder Dislocation

A recent college grad, Dan plays in a New Jersey recreational rugby league. His shoulder had never given him any problems until an opposing player slammed into his upper body when he was facedown on the field. He suffered a traumatic dislocation. Both Dan the rugby player and Laura the swimmer have unstable shoulders. But he needs surgery and she needs therapy to correct a muscle imbalance.

If your shoulder dislocates as the result of trauma, even partially (it’s called a subluxation), it’s time to see an orthopedist. The labrum, a ring of fibrocartilage that deepens the socket and helps keep the ball in place, often tears. The ball, or humeral head, can scrape against the socket, dislodging a wedge of cartilage. These are two good reasons younger people with normal shoulder anatomy who suffer a single traumatic dislocation have up to a 90 percent chance of suffering more dislocations if the damage isn’t repaired. In many cases, labral tears in the shoulder require surgery. An unstable shoulder can lead to osteoarthritis down the road.

In some cases, as with partial tears of the rotator cuff, if you can decrease the symptoms by improving muscle function, you can avoid surgery even though a structural problem is still present. In the case of a labral tear, you may need surgery even if the pain goes away. Degenerative changes can occur over time if the shoulder is left untreated. Your orthopedist can help you to decide on a course of action.

Osteoarthritis

Shoulder arthritis isn’t as common, or usually as debilitating, as arthritis in the knee or hip, but the shoulder is still vulnerable, at both the AC joint and the ball and socket joint. Because doctors don’t yet know how to stop the overgrowth of the bone tissue, our options are limited. Manual therapy that relaxes the muscles and decreases the pressure of muscle tendons pulling on the joint can ease pain and stiffness and may prolong the life of a joint. Anti-inflammatory drugs and corticosteroid injections, as long as they’re not overprescribed, can be helpful. Severe cases of osteoarthritis can call for more aggressive measures if the patient is otherwise healthy enough to tolerate surgery. For the glenohumeral joint, that would be

Dr. Kelly

I have a patient, Rebecca, a forty-year-old woman who fell down and shattered the top part of her humerus, her upper-arm bone. A trauma surgeon came in and pieced the bone back together. So the bone fracture was fixed, but the shoulder joint and the muscles were a disaster. Her shoulder joint collapsed because the accident had cut off the blood supply to the area and the surrounding muscles had shut down. She was in excruciating pain and became addicted to narcotic pain meds. We removed the dead bone and converted her to a ball-and-socket shoulder prosthesis. She’s got her life back.

joint replacement, replacing damaged bone and cartilage with a metal-and-plastic implant. For the AC joint, the procedure entails cutting away a portion of the collarbone and leaving a space between the bone and the tip of the shoulder blade. Some AC joint injuries may be repaired through surgical reconstruction.

SHOULDER

The shoulder is arguably the most mobile joint in the body, but for this privilege it sacrifices stability. It is held together more by soft tissue than solid bony connection, so it is important that the tissue is maintained. All possible movements are achievable by the shoulder: flexion, extension, adduction, abduction, circumduction, and coupled movements (forward, back, toward you, out to the side, in a circle, and combinations of these). If you’ve ever seen a baseball pitch, a tennis swing, a gymnastic rings event, or a Cirque du Soleil performance, you can start to appreciate what the shoulder can do.