Stress management techniques

Can you believe it’s the end of June already? I don’t know how we’ve got here, nor do I know how this is the last in the stress management series already! It’s flown by.

If you get my weekly emails (thanks for signing up!) you’ll know it was summer solstice on June 21stand we had a full moon a couple days before. I’m telling ya – things get funky at that time!

I certainly found myself having to adopt some stress management techniques to offset some crazy decisions I’ve made and to put up with the craziness of the world around me interrupting my zen!

Today, I’m going to share some techniques that are not only evidence based and recommended by the smart science people but ones that I personally use myself in order to help calm the stress. If you haven’t checked out the posts on what stress is and how it affects you read parts one and two of this month’s series as it’s going to help give you a foundation and make this part, make much more sense!

Firstly, I’d like to preface this post by saying that this is by no means an exhaustive list of things that may or may not help you get through a stressful period. It’s a bit of trial and error with these things and what works for one won’t necessarily work for another. Worth giving them a shot regardless though as you never know what’s going to be the best thing for you until you try it out.

Change your environment

Such a simple yet often overlooked place to start is your environment. When you start to feel stressed, for whatever the reason may be, it’s quite difficult to get in to any of the other recommended techniques before you’ve moved from where you physically are. So, if this is at your work desk for example, get up and grab a drink or walk to a communal area; if it’s at home after an argument with your partner in the living room go upstairs to the bedroom or in to the kitchen. Once you’ve found somewhere that’s allowing you some mental space, it’s time to start with some of the following.

Breathing

We all breathe every day without thinking about it but when we start to put some intention behind our breathing (in this case stress reduction) it’s amazing the clarity we get. I find the following breath pattern really helpful so it’s something I’d recommend you try:

  • Inhale for a count of 4
  • Hold for a count of 4
  • Exhale for a count of 8

It doesn’t really matter what numbers you put on the inhale, the hold and the exhale as long as the exhale is longer than the inhale it should help!

Best thing about focussed breath work is that nobody even knows you’re doing it so it’s a really easy one to add in to a working day or when you’re in a situation where you’re surrounded by a lot of people and unable to change your environment as easily.

Exercise

It keeps cropping up doesn’t it!! Exercise releases endorphins, serotonin, oxytocin and dopamine which are all natural feel good hormones – also, interestingly, the same ones released when people take cocaine.

Now when people hear the word exercise they instantly think of the gym or some vigorous form of activity. Whilst it’s true that the definition of exercise is carrying out activity for a specific purpose e.g. improving health, improving strength, flexibility or endurance, we don’t need to go to the gym to gain the exercise benefits for stress relief. Something as simple as going for a walk, swimming or casually riding a bike is going to do the same thing. Likewise, and a personal favourite of mine, yoga.

Yoga is a spiritual practice that connects you to your body and your breath. It’s a time for you to understand yourself and a time for you to leave the outside exactly there. Yoga can be done anywhere as well. If you haven’t tried yoga before it’s something I would definitely recommend!

Diet and nutrition

We all know the benefits of a healthy diet on our physical health but what about our mental health and wellbeing? We’ve already discussed how stress increases our blood pressure. The micronutrients (effectively vitamins and minerals) we get from eating healthily – polyphenols, B vitamins, vitamin C and vitamin E in particular – have hypotensive properties helping to reduce our blood pressure as well as inflammation which is also heightened during periods of stress. Remember we spoke about gut health as well and how it gets thrown out of kilter when we’re feeling under pressure? Well, by keeping your digestive tract healthy we can reduce the likelihood of stress developing. Eating foods rich in fibre will aid this.

What about the macronutrients – protein, fats and carbohydrates? How do they impact stress?

All carbohydrates prompt the brain to develop serotonin which we already know is a feel-good hormone. For a steady supply of this, it’s better to eat complex carbs which take a longer time to digest. For fats, we should lean towards those foods high in fatty acids (Omega-3s) as this can prevent a surge in cortisol as well as protecting against depression. As for proteins, they tend to be high in tryptophan which has been found to have a calming effect as well as aid the production of serotonin.

Some examples of stress busting foods:

Berries, green leafy veg, bell peppers, oranges, dark chocolate, fish, poultry, nuts, avocados, red wine, oats, yoghurt, milk and seeds.

Massage

Massage has been shown to improve all of the physical signs of stress – blood pressure, heart rate, respiratory rate to name a few – as well as improving the release of our endorphins, oxytocin, dompamine and serotonin. The power of touch is calming in itself (how often do you feel like you want a hug when you’ve had a crap day?) as it helps you feel safe during a time where you are on high alert perceiving a threat. Massage, like yoga, really is something that treats the body and the mind.

Sleep

Probably one of the most under-utilised things for recovery gains is sleep. Adults should be aiming for 7-9 hours of uninterrupted sleep per night in order to capitalise on all of its wonderful benefits. I’m going to do a full series on the benefits of sleep as it deserves a whole section of its own! In a nutshell though, when we’re stressed, we often find it difficult to turn off our internal chatter which can make it troublesome to relax enough to fall asleep. Sleep is our bodies time to rest and replenish so it really is key. Have a great evening routine and you’ll probably find sleep a lot easier. I also love a nap – it’s not just for kids!

Deal with it

Once you have managed to come down from stress and start putting strategies in place to help you stress less, it’s really important that you put some time aside to deal with the stress you’re under. It might be working out how to leave the job you’re in or how to better manage your pregnancy or how to say no to the things you don’t want to do. Only once we’ve identified and dealt with the stressors at play will we truly be able to move forward. I like journaling as a way to do this and recently purchased a bullet journal which I’m loving.

 

There we have it! Some simple, quick ways to help manage periods of stress. Try incorporating some of these in to your week and see what difference it makes.

As always, any questions just get in touch!

Until next time x

Stress and recovery

Welcome back to June’s stress series! Something that is really stressing me at the minute is the weather. It’s supposed to be summer! Stop with the hailstones and storms already please! Ended up soaked earlier going from the house to the car – ridiculous!

In this post we’ll be looking at how stress impacts your ability to recover sufficiently and the longer-term effects this can have. It’ll be mega useful for you to check out what stress is first of all so if you haven’t already check out last week’s post.

Something we didn’t touch on last week was the parasympathetic and the sympathetic nervous system. The parasympathetic system allows us to rest. It’s responsible for restoring the body and conserving energy by reducing respiration and heart rate and increasing the digestive process. It’s sometimes referred to as the ‘rest and digest system’ and helps us calm down after a period of sympathetic activity. The sympathetic nervous system basically does the opposite – increases the production of cortisol and catecholamines (‘stress hormones’), increases heart rate, blood pressure and heart rate volume and makes it really difficult to relax. It’s most active during stressful situations (remember fight or flight? Thank your sympathetic nervous system!)

It is so important to have regular recovery from stressful scenarios to activate the parasympathetic nervous system and reduce the sympathetic response. Remember, these scenarios can be a host of different things: your workouts, your workplace, your Physio, your friends, your family – the list goes on.

When the parasympathetic nervous system is in charge, we allow our body and brain the opportunity to recharge for the next thing we have planned. Strong indicators of someone who has a good recovery regime are things along the lines of a reduced resting heart rate, a high heart rate volume, reduced respiration rate, reduced blood pressure, healthy bathroom habits, higher sex drive, reduced muscular aches and pains, reduced likelihood of injury, higher energy levels, reduced feelings of anger, sadness and overwhelm – all mega positives!!!

Stress inhibits these because it, quite simply, doesn’t let the parasympathetic system come in the door and allows cortisol to have a house party. Whilst the parents are away and all that!!

But what’s the problem with cortisol having a rager in your house? It’s just having a good time, right?

Well constant cortisol production can lead to a bunch of nasty things. Think weight gain progressing to obesity, acne (nobody wants spots after puberty!), thinning skin, bruising like a peach, severe fatigue, slower healing ability, redness of the face and skin, global muscle weakness, higher blood pressure, headaches, increased irritability, difficulty concentrating, anxiety and depression. It’s not the cool guest anymore is it?

Have you ever been to a house party that the Police have had to close down? I have when I was out in America. I went to a frat party, things got out of hand, the Police came to shut it down. A bunch of folks went and hid so that once the Police left they could restart it.

Cortisol can be like that as well – just when you’ve managed to get a bit of recovery in and the parasympathetic system starts to take control, cortisol brings its pals adrenaline and noradrenaline and comes running in from the kitchen causing havoc again. It’s like a wee gremlin!!

And the cycle starts again. Sometimes this cycle goes on for a long, long time and can be very difficult to break. There’s a reason that we find we get stuck in a stress cycle and that’s because the more time we spend under stress the less resilience we have to stressful situations i.e. something that we normally wouldn’t find stressful suddenly becomes difficult to manage and our sympathetic nervous system kicks in quickly to try and protect us. It’s a bit of a nuisance really!!

It’s not all doom and gloom! There are ways to interrupt this cycle and ways to kick cortisol out for good.

Tune in to the next instalment to find out how!

Until next time x

Let’s talk about stress baby

We all get stressed – good, bad or indifferent we will all experience varying levels of stress during any course of a day or week. Not all stress is bad – we need an amount of stress to get us up in the morning or what’s the point? But sometimes it gets a bit OTT and starts to cause problems.

Best place to start – and the main focus of this post – is what actually is stress?

Stress is a term that gets thrown around a lot but it’s not something that we necessarily fully understand. There are so many different definitions of stress as well that it can be hard to pin point. I personally find this one here from Dr Shiel (2016) the best one to fully cover all elements of the stress continuum:

‘In a medical or biological context stress is a physical, mental or emotional factor that causes bodily or mental tension’ 

Let’s unpick this together. We are purely looking at the medical and biological definition here. Out of interest I googled ‘what is stress’ to see how many definitions would arise from this simple search. Interestingly, a lot of these looked at how stress made you feel but didn’t necessarily touch on the medical or biological explanation for this. Please don’t take this to mean that medicine and physical health is the be all and end all – it’s absolutely not. However, often medical definitions can be quite useful in helping us explain phenomenons.

We can also see that it’s a physical, mental or emotional factor. That’s right it’s not just a feeling that you get (and partly why I don’t enjoy the definitions that focus solely on the feeling)! This helps us understand that we can get physical symptoms associated with stress so please don’t be offended if your Physio starts asking you if you are under any stress at present or if you have anything upcoming in the near future that may be impacting your subconscious. Commonly, stress presents in the neck, shoulders and jaw but equally I’ve seen people with foot pain that settles when stress is addressed. We know that stress can raise emotions in us – anger, fear, worry to name a few – and it’s interesting how family and friends describe their loved ones during periods of stress. Have a think about your own life at the minute. Do you know someone who is going through some stress just now? Has their personality changed a little over this time? How would you describe them to your closest friends over a coffee when they ask how they are? And we also know that there is a mental component – you can’t concentrate as well, your recall and memory aren’t as great, people describe a sensation of fogginess. This is all completely normal when we’re under periods of stress.

Finally, this definition tells us that stress presents as bodily and mental tension. I hear that!!! Think about a time when you’ve been stressed. How would you describe yourselfduring that time? Is it the same way that you described your friend or family member up above? I know for me tense is the right word. Not only do my muscles feel tight and my joints feel stiff (‘I’ve just not got the same range of movement in my squat that I did’) but I feel constantly on edge and at high alert. A pin dropping would be enough for me to whip around ready to protect myself. Why is that though?

Well, stress invokes the fight or flight response. Time to get technical and complicated! Fight or flight is controlled by our endocrine and neurological systems. Hormones, in particular adrenaline and noradrenaline, surge through our body in preparation for rapid muscular activity. We find our heart rate increasing (get more blood to my muscles please), our breathing becomes shallower (I need as much air as I can possibly get so I’ll try breathe faster), our blood pressure goes up (GET THAT BLOOD TO MY MUSCLES PLEASE!) and we start to slow down – or stop – our digestion (I totally don’t need you to break down that chocolate I just ate). Attention is directed away from glands responsible for tear production, our pupils dilate and we don’t have as much peripheral vision (I need to see as much as I possibly can right in front of me right now thank you very much). We also don’t need our bladder to be taking up any energy so it will relax (seen the shows where people end up weeing themselves out of fright? That’s why!) and there’s no way in hell I need a man or lady hard on right now so forget about sexual function (no time to reproduce – we need to be safe first!). As these hormones surge through us, we find our musculoskeletal system is the focus. We are either going to run like hell and get as far away as we possibly can (needing lots of muscular energy) or we’re going to stand our ground, protect what’s ours and fight like hell (needing lots of muscular energy). In preparation for either of these eventualities we may find we start shaking as this system gets ready to jump in to action.

All of this happens in a split second and once the threat is removed we ordinarily are able to to take a deep, calming breath and allow our parasympathetic nervous system to come back in to play contracting our bladder again (thank goodness we’re not constantly peeing ourselves now), giving us back our peripheral vision and tears (this is partly why after a frightful event people can burst in to tears), allowing us to start getting erections again (hallelujah!) and enabling our musculoskeletal system to relax giving us back our range of movement (namaste).

But what could possibly be perceived as such a threat that we could invoke a flight or fright response? Don’t get me wrong – the above description is drastic – but when we are under stress we are operating at a level of the above because we perceive whatever this stressor is to be a threat to us. Our natural instincts of survival come in to play (thanks to our ancestors for supporting the species to this point) – and we begin to revert slightly to primordial self.

Remember at the start I said stress could be caused by negative and positive things? Before going any further, take a bit of time just now to jot down a few things that have happened recently and how that caused you stress. This could be things like getting ready for a night out, moving to a new house, buying a new car, going on holiday, being given a new task at work that you don’t think you’re equipped for, being in an accident, suffering a recent bereavement – the list goes on. Have a think about how you felt, what happened physically and how you feel now that you’ve come out the other end. Spend some time on this and put thought behind it.

Often, we find that stress can be caused by external and internal factors. The external factors are things like your environment, relationships and all of the things that you face during an average, normal day. The internal factors that can impact on stress are how well you are prepared to deal with stressors: things like your nutritional status, sleep hygiene, emotional wellbeing and physical fitness all play a part in how you handle stress and stressful events. We will talk about how to manage these things in the next instalment.

With some ailments, we can be more susceptible to picking them up due to our age (things like arthritis), whether we are male or female (remember frozen shoulders?) and what our ethnicity is (think sickle cell anaemia as an example). Stress however doesn’t discriminate the same way these things do. It can pick on anyone of any age, ability, sexuality, gender, religion or ethnicity. It is highly individualised and therefore very difficult to compare to someone else’s stress. Things that cause one person’s stress may be actually quite relaxing to another person and vice versa.

And all of this is why stress can be so difficult to manage and why it tends to need input from many different people to help you go through the stress, beat down its walls and come out the other side.

Here’s to stress right! We will touch on things like cortisol and dopamine, stress management and how this all impacts on your recovery over the rest of the month but for now I’d really love it if you would get up, stretch, think of something that’s happened recently that’s made you smile or laugh out loud. Relive that moment and feel the joy that it brought you. Now, if you’re with someone else turn to them, if not pick up your phone and pick whoever you like to ask them how they are. Make someone’s day!

Until next time x

Why are shoulders so crap? – Part 3

Alas, and so it must be; all good things come to an end!

In the final instalment of May’s ‘Physifitt does shoulders’, we’re looking at common treatment methods and what techniques may be more beneficial than others. If you haven’t already, check out Part one and Part two on shoulder anatomy and common injuries. It will make this part a lot easier to follow.

In the last post we looked at the top 3 issues that we Physios commonly see and treat: frozen shoulder, rotator cuff issues and cartilage tears. This post is going to look at treatment modalities we use to assist your recovery from these issues. Remember folks, get yourself assessed by a Physio before commencing any treatment.

Generally, shoulder pain will improve by itself in around 2 weeks. However, you can often help this recovery by giving yourself some PEACE and LOVE. For those of you who follow me on social media, you’ll have seen the infographic I posted recently about this which was originally published by the BJSM. Historically, we advised on protection, rest, ice, compression and elevation (PRICE) in the first instance following injury. As everything, we’ve moved on from here and are starting to think that PEACE and LOVE might be more beneficial. Let’s take the PEACE first.

The P is for protect.  We want to have a period of restriction for 24-72 hours immediately post injury as this helps to reduce bleeding to the area. The E is for elevate which says what it means on the tin – get the arm higher! This is going to help reduce swelling. We know it’s not got great evidence to support its use but it is still recommended due to the low risk. A is for avoiding anti-inflammatories. Inflammation is the first part of the healing process and we actually need this to help kick start our recovery. Anti-inflammatories reduce this and their use – especially for prolonged periods and at high doses – can be detrimental for long term recovery when used in the immediate phase post injury. C is for compress – tighten it up! Tape, bandages, pushing it all help reduce swelling and bleeding as well as giving some feedback for decreasing pain. Finally, the E is for education. It’s important for us Physios to help you understand straight away the likely recovery times, what’s happened, that there is nothing serious occurring and that you will recover. It’s also important for us to help you take an active approach to your recovery – things like massage, acupuncture and electrotherapy in the immediate stages post injury do virtually nothing and have been shown to be more detrimental in the long run than taking an active approach.

After the first 1-3 days have passed, we’re looking at giving ourselves some LOVE.

L is for load. Listen to your body and be guided by your symptoms on this one. If your pain levels exceed 5-6/10 then it’s probably not a good idea to continue with that task. But loading an injured area early has been shown to have positive outcomes by improving repair and remodelling phases (the next 2 phases of healing after inflammation), improving tissue tolerance so it’s less likely to ‘fail’ treatment and improves the strength and capacity of muscles, tendons and ligaments which will improve your overall performance. O is for optimism. It’s so easy to become down, get frustrated with yourself when you’re injured, become annoyed that you can’t do the things you normally do but remember that you will get better, nothing serious or sinister has occurred and it’s safe to participate in the rehab plan your Physio has created – they would have referred you on to someone else if they were concerned about any of these things! V is for vascularisation. Cardiovascular work like walking, rowing and swimming all help to keep blood flow going to the injured area boosting the healing process as well as keeping it mobile to reduce any stiffness or reduction in range of motion. Finally, E is for exercise. Exercise in general will help with your flexibility, strength and proprioception early on in the injury process. Remember that it’s ok to be uncomfortable as exercise isn’t supposed to be easy but pain shouldn’t be occurring – remember >5-6/10 stop! (if you want to read more on Peace and Love check out the BJSM website).

And that’s the first few weeks! Simple right? But what happens next?

Well, your rehab plan should be progressed to make it harder! I’m sure that’s exactly what you wanted to read! Once the acute symptoms have settled, we can make things more difficult to make sure we have full range of movement. It’s interesting as often purely stretching will be prescribed to try and achieve this but there’s a host of research now advocating the use of strengthening (in particular the eccentric phase) as using resistance helps the joints move through their full range especially on the lengthening part of the movement. That’s not to say stretching doesn’t have a place – of course it does! – but let’s maybe think a bit wider and incorporate both fitness elements to ensure the best possible position for recovery.

When your range of movement has improved this is when we’re going to push you further again and start looking more at strength and conditioning principles – think global and explosive! We’ll be starting to bring in lower reps and cranking the weight up to make you work – it won’t be easy and your pain and RPE should be taken in to consideration at this point. We will also be looking at things like throwing, bouncing, dropping and catching. Interestingly, this is where most people drop away from Physio. Generally, the initial symptoms are under control and pain has almost fully settled but there’s still work to be done in terms of building that tissue tolerance to make it BETTER than it was before your injury. What’s the point in taking you purely to where you were when you got injured? You got injured for a reason at the end of the day so should we not strive to be better than this state?

Once this phase has been completed, you are generally good to go. After a final evaluation where all of your outcome measures should have improved your Physio will likely discharge you back to fitness. RESULT! You made it – well done =D.

I’ve focussed a lot on active recovery through this post and that’s because it really is what has the most support in our research and evidence for long term recovery with the lease harmful effects. When people think of harm they think of physical harm like bleeding from an injection for example. We’ve found a lot of emotional harm can come with excessive use of manual therapy – things like reliance upon your therapist, beliefs being instilled that harm has occurred and it’s not safe to move or load, encouraging avoidance behaviours and negative thinking. None of that’s very good is it?

This isn’t to say there isn’t a place for manual therapy. It’s something I still use in practice. When you look at deep tissue massage for example there’s some evidence suggesting that the power of touch is wonderful at assisting with rapport and reducing sensitivity, but it isn’t what’s going to make you better in the long term. That’s the same with acupuncture – there’s some evidence to support its use in creating inflammation to promote the healing process as well as stimulating the body’s natural painkillers but it’s not what’s going to make you better in the long term. Electrotherapy – things like ultrasound and interferential – has been shown to help with building rapport and reduce sensitivity as well but it’s not what’s going to get you better in the long term.

What do all of these things have in common? PAIN REDUCTION!!!!!

They MIGHT help at reducing your pain giving you a window of opportunity to work through your rehab plan, engage in social activities, stay at work and live your life.

My main take away with manual therapy is that it’s not a demon but the narrative that comes along with it is. Please understand that no amount of manual therapy is going to ‘fix’ or ‘cure’ you. It isn’t the thing that’s improving tissue length or increasing your strength. Give yourself some credit – you’re the one doing that!! You’re the one putting in the effort day in and day out to get yourself better. You’re the one that’s trying your damned hardest to improve your symptoms by sourcing help. Manual therapy facilitates your recovery but it’s YOU that’s going to get there with the Physio coaching you through your rehab plan along the way.

It is important to note that sometimes Physio doesn’t work for a variety of reasons and we may then make a referral to our medical colleagues to review you. They might talk to you about exploring injections which is basically a steroid being put in to the joint to reduce inflammation or even surgery. Most Orthopedic surgeries don’t have great outcomes and ordinarily a little longer with the Physio will get you there so don’t go jumping straight for the scalpel without doing your research and chatting with your provider first.

And there we have it folks! A brief overview for shoulder treatment although I suppose the principles could be applied to most soft tissue injuries. I’ve tried to keep things to what we Physios should be doing according to our governing bodies recommendations but if you have any questions or queries about anything at all just get in touch!

Thanks for taking the time to be a part of my shoulder series. I’ve really enjoyed putting this together and I think I might now have a theme of the month going forward. If you have any suggestions on what you’d like to see let me know!

Until next time x

Why are shoulders so crap – part 2

Hi folks – thanks for coming back for more shoulder chat!

As most of you know already, May is the ‘Physifitt does shoulder series‘ after one of my clients asked me why shoulders were so crap and after my own shoulder injury flared up again. Here we will start to discuss common and rare shoulder injuries and our final section will look at treatment. Part one focussed on shoulder anatomy and if you haven’t already, check it out. It’ll give you a good foundation to help this segment make a little more sense.

It’s going to be a lengthy one today so go grab a coffee, get yourself comfy and buckle in for the ride.

Before we start unpicking shoulder injuries some background information might be helpful. Shoulder complaints are the third most common injuries that a Physio will see. That shows you how normal it is to experience an issue with your shoulder at some stage. No doubt when you’ve been down the pub, out with friends or in the gym and mentioned a niggle in your shoulder someone around you has said ‘I hurt my shoulder too!’. It’s common, it’s normal and Physios are well placed in helping you recover.

Remember back to the anatomy post where we spoke about how the shoulder isn’t just your arm? Well that means that injury can arise from any part of the shoulder complex making it an interesting area to treat – one person’s shoulder pain won’t be the same as another’s even if the symptoms are in a similar area.

Just how common is common though? Sorry ladies but if you’re a woman and aged between 45 and 64 you’re most likely to develop issues with your shoulder whereas men aged between 18 and 44 are the least likely group. Take a moment to think about why this might be. Why women? Why that age group and not older? Surely things get worse as we age right? I’d like to hear your thoughts on this so please do get in touch!

Over any one year 47% of the overall population may be dealing with shoulder pain. When we bring this down to any one month it’s 31% and if we look over a person’s lifetime we reach a 67% chance of shoulder symptoms. To keep it simple, what this means is that in a month, a year or over the duration of your lifespan it’s likely that you will develop an issue with your shoulder.

I can already hear you telling me you didn’t come here for stats and you want to know what these issues are. Let’s start unpicking these together. We will talk about 3 of the most common issues today in detail – frozen shoulder, rotator cuff problems and cartilage tears – before touching on some of the rarer conditions such as bony injuries, referred pain from the chest and nerve injuries.

Frozen shoulder

Let’s start here. As with other shoulder issues this is extremely common. It has a couple of different names such as adhesive capsulitis or contracted shoulder and can last a couple of months or more commonly 1-2 years.

Remember when we looked at the anatomy we spoke about that loose fibrous structure called the capsule that helps to keep the joints lubricated? Well it’s this that’s predominantly the issue here. It can become sticky, thickened or scarred and doesn’t provide the joint with as much fluid meaning that it gets grumpy when being asked to move. Whilst we aren’t machines it can be likened to a bike chain that’s not got any oil on it. It might get rusty (thankfully we don’t!) but the bikes movement isn’t as smooth and sometimes doesn’t want to go at all which is a similar situation here.

Frozen shoulder can occur from primary reasons (the shoulder itself) or secondary reasons (something else has had an impact). We’re not really sure exactly why frozen shoulders develop (the researchers have found a like with persistent inflammation that causes scarring and thickening of the capsule but we don’t know where this inflammation really comes from) but we do know that if there’s been any period of immobilisation – so following a fracture when your arm has been in a sling or after a stroke or if we aren’t overly active in maintaining our full range of movement (think sedentary lifestyles and desk based jobs) – then we’re more at risk of developing frozen shoulder. Secondary reasons include things like diabetes, lung disease, infection and neck issues. If you’ve been diagnosed with any of those issues, then you may find yourself more susceptible to developing frozen shoulder.

The symptoms of frozen shoulder are usually described as a dull aching pain around the shoulder joint itself worsened when the arm is moved, at night and when in bed. Generally, people struggle to get the arm above head, round their back or rotating to the side meaning even tasks like driving and changing gear can cause significant pain.

Often frozen shoulder develops gradually over time. The first phase (‘freezing’ or ‘painful’) is when the capsule is starting to become thicker and reduce its lubricating properties. This is when the dull ache develops, and movement starts to become stiffer. It’s quite difficult to diagnose frozen shoulder at this point because it is only just developing and can last up to 9 months.

The second phase (‘frozen’ or ‘stiffness’) usually comes with a lot less pain (result) but movement is generally significantly affected, and it can become really difficult to move your arm away from your body. Your body naturally wants to protect it so keeps it close. This phase can last up to a year.

The third and final phase (‘thawing’ or ‘resolution’) is when you generally find that your symptoms start getting easier. You’re able to move your arm more than previously and your pain is vastly reduced although may still be present. It can last a long time though and may be another year before you reach this stage.

To sum this part up, frozen shoulders are common and generally you have a dull ache around your shoulder that’s worse with movement and at night. It has 3 phases and may last anywhere from a few months to a few years. Don’t worry though – it can be helped! Treatment and prevention will be discussed in the next segment.

Rotator Cuff Injuries

Moving on to rotator cuff injuries now. Remember the rotator cuff from our anatomy segment? It’s the small group of muscles and tendons that help keep the shoulder in its socket. Just like everything else with the shoulder, it’s really common to injure this area.

The rotator cuff can become irritated and inflamed for a host of different reasons. Repetitive overhead tasks tend to be the most common cause (think painting and decorating) but playing a lot of racket sports like tennis and badminton, being involved in throwing sports like javelin or cricket, occupations including carpentry or those where heavy lifting is required as well as age and genetic factors all work together to predispose you to rotator cuff issues.

You might have heard the term shoulder impingement being thrown around (get it?! I’m hilarious). This term is now quite outdated as it reflected inflammation of a single tendon whereas we have now found, through research, that generally the full cuff is involved in some way including altering movement mechanics around the shoulder blade to offset the pain experience. We tend to class these injuries now as rotator cuff pain syndrome (the medical world loves itself a syndrome) or simply a rotator cuff injury.

I touched on age a couple of paragraphs ago. We know that as we age our collagen production reduces. Collagen is a key player in muscle and tendon structure so, as collagen reduces, we can find that we develop injuries in muscles and tendons. The rotator cuff falls under this bracket. This is entirely normal the same way as your hair turns grey and you get wrinkles on your skin. Try and think of age-related changes to your tendons as tendon wrinkles rather than degeneration or wear and tear. It’s way more normal and a lot less scary! I can promise that you aren’t degenerating away to nothing nor are you tearing things with every movement you make. It’s normal to age!! We are so lucky if we get to experience the ageing process as so many people unfortunately don’t.

It’s really great to read about the risk factors but the symptoms are just as important. You will tend to find the following:

  • Dull ache deep in the shoulder
  • Disturbed sleep especially when lying on the sore side
  • Painful arc – lifting your arm to the side is ok for a bit then gets sore and can then feel a little easier
  • Weakness in the arm

Pretty similar to the frozen shoulder right! This is what makes it so difficult to diagnose.

Sometimes we can find that our rotator cuff becomes calcified – a wee bit of calcium grows within the tendon. This can cause a lot of clicking and inflammation so your symptoms can be intensified.

Occasionally, and especially common after a traumatic injury a fall or accident for example, the rotator cuff can tear completely. You would notice significant pain and reduction in movement as well as a hell of a lot of weakness in comparison to the other side.

That’s rotator cuff injuries in a nutshell. There’s a whole load more information I could add to this and I might even do a specific rotator cuff injury post so as not to bog you down in stuff at the minute!

Cartilage injuries

Take a minute to remind yourself about the cartilage of the shoulder and what its purpose is.

The cartilage of the shoulder is also known as the labrum and can be injured in different ways. They’re classed as labral tears and can be quite tricky to differentiate between.

The first common tear is when the labrum is torn completely off the bone. This results in the humerus not sitting in the socket properly and so the shoulder becomes subluxed or even dislocated.

You can also fall victim to a Bankart lesion which is when the front of the labrum is torn and a small pocket develops in the cartilage itself. This can then cause the humerus to fall in to the area effectively dislocating.

Remember the biceps muscle and it’s two heads? The long head can sometimes pull away from its origin on the labrum taking a piece of the cartilage with it. We call this a SLAP tear which just refers to the location of the cartilage that is injured (superior labrum anterior posterior or more simply the upper front and back).

Sounds pretty nasty right? Bits of cartilage being torn and pulled around. But what does it feel like? You would commonly notice a deep dull ache in the shoulder which is accompanied by catching, clunking or popping sounds and feelings (not a click – it’s more than that). It often feels really deep within the shoulder rather than near the skin and you’ll normally struggle a lot with overhead movements. You will also notice a decline in the strength of your arm and might find it harder to participate in your hobbies and normal daily activities.

These things don’t just happen though. Generally, there needs to have been some sort of trauma so a fall on to an outstretched arm or landing directly on the shoulder, a sporting injury (think rugby and gymnastics when in the rings) or even a car accident could all cause a tear to the labrum. It’s quite unlikely that you would develop this gradually over time unless you are elderly where age related changes can impact the cartilage.

Well done on getting this far. It’s a lot of information and a thanks for keeping up! We’re moving on to slightly rarer structures to become injured but injured they can get!

Bursa, bone and nerves

Your bursa structure, bones and nerves can all also be injured. Bursas can become inflamed causing pinching like feelings and often sharp pains on movement and dull aches at rest. Your bones can fracture which I’m sure you’ll appreciate can be extremely painful and will normally cause the arm to look different as well. Nerves can become irritated where they begin to lack flexibility and so you can feel numbness, tingling, weakness and pain further down the arm and in to the hand as well.

Heart issues

Remember that pain in your shoulder doesn’t necessarily have to be coming from your shoulder or the structures of the shoulder girdle. If you are having a heart attack, struggling with angina or indigestion you can find that your shoulder will be painful as well. This generally travels to the face and jaw as well as further down your arm.

Remember folks, this is a medical emergency and so if you start to notice any of these symptoms don’t hang around – call 999.

Cancer

The big C word. That’s right – sometimes shoulder pain can be because of cancer. This includes cancer of the bones themselves but also something a little rarer called a Pancoast Tumour. A Pancoast Tumour is when there’s a tumour in the top of the lung which sits at the clavicle. You will generally find that you have weakness and severe pain in the arm and scapula, breathlessness, have a persistent cough that won’t go away, weight loss, general fatigue, grey coloured skin and Horner’s Syndrome which means flushing on one side of the face, not being able to sweat on this same side, a smaller pupil and a drooping eye lid.

Pancoast tumours are extremely rare and are unlikely to develop in the general population. You’re more at risk if you’re a smoker or are surrounded by secondary smoke or have been exposed to asbestos, diesel, nickel or gold perhaps through your occupation.

If you do have any of these symptoms or are prone to the risk factors have a chat with your GP about things and see if there’s anything that can help. There are loads of things out there to help with stopping smoking for example and your GP has all this info ready for you.

And there we have it folks!!! Common and rarer reasons as to why your shoulder may be sore. This is by no means exhaustive there’s a hell of a lot of other reasons too -neck and mid back referral and don’t even start me on persistent pain problems! – but I think I’ve probably bored you with all this for long enough.

Remember any questions or anything you would like to know more about get in touch. If you’re suffering with shoulder pain give me a shout and I can help you understand it a little more.

 

*Please note that this is for information purposes only. Please consult a trained medical professional before reacting to any of the information included in this post*

 

 

Why are shoulders so crap?

Welcome to the ‘Physifitt does shoulders’ series!!

If you’re part of my mailing list (if you’re not what are you playing at!! Sign up here: Physifittyou will know that my longstanding shoulder injury has raised its ugly head again and that a client of mine has become increasingly frustrated that his shoulder injury keeps flaring up.

It started by us having a conversation at his last session stemming from the question ‘Why are shoulders so crap?’

My aim is to start posing explanations in an attempt to answer this question over a series of blog posts throughout the rest of May. A new topic will be live each week so make sure you keep checking back in!

Part one will be focussed on shoulder anatomy.

Let’s start at the beginning. The picture above shows a very basic view of the shoulder complex. It’s made up of more than just your arm. It’s your arm (humerus), shoulder blade (scapula), collarbone (clavicle), breast bone (sternum), mid back (thoracic spine) and ribcage (inventively – ribcage) all working together to produce movement at the shoulder area itself.

Now these are all bones and if you’ve ever seen a skeleton you know that it doesn’t move by itself (if it does that’s quite spooky). It needs muscles, ligaments, tendons and nerves to get from one place to the next.

The nerves that supply the shoulder complex with its motor and sensory functions are located in the neck and upper back which leave their root and merge at the brachial plexus (sits just near your clavicle) to then innervate the arm. If there’s an issue with any of these areas, then this can cause problems to the shoulder that can sometimes be confused with being a local shoulder issue. More on things like this later!

Next up are the ligaments. Ligaments are strong fibrous structures which are passive (they don’t move actively) and are important for stability and preventing dislocations. The main shoulder ligament is called the glenohumeral ligament which is formed of 3 parts and this structure also forms the joint capsule which helps to keep the shoulder lubricated – think WD-40! The coraco-acromial ligament holds the coracoid (part of the scapula) to the acromion (pointy bit of the shoulder) and is commonly involved in impingement issues (more detail on this over the month). The coraco-clavicular ligament is actually 2 ligaments that attach the clavicle to the scapula. They are extremely strong but can be injured and will often be the cause of AC (the joint between your scapula and clavicle) joint issues. Finally, the transverse ligament holds the long head of biceps in its groove within the shoulder as it travels to the labrum.

The main muscles and tendons of the shoulders include the rotator cuff (supraspinatus, infraspinatus, teres minor and subscapularis), deltoid (anterior, middle and posterior), pectoralis minor and major, latissimus dorsi, trapezius (upper, middle, lower), subclavius, levator scapulae, teres major, rhomboid minor and major, serratus anterior, biceps (long and short head), triceps (long, lateral and medial head) and coracobrachialis. That’s a lot, and not all, of muscles within this region! All of these muscles have tendons at their origins and insertions which can also become injured. Muscles are active structures that can contract and relax. They also have a really good blood supply which makes their healing times a little less. Tendons however don’t have quite as good a supply and so can take a little longer to heal. The function of a tendon is to shift force from one region to the next in order to initiate movement.

This is all well and good but how does this movement actually occur? Especially smoothly? Surely all of these structures can’t possibly work together without something supporting them.

This is where structures like fascia (I’ve done a previous post on this so won’t be covering this here), bursae, labrums and even the skin layers come in to play.

Bursae are small fluid filled sacs that help to reduce friction between 2 surfaces. They are present throughout the entire body (easiest one to feel is at the front of your knee. The squashy bit just under your knee cap – poke it. That’s a bursa!) and help with fluid movement. In the shoulder specifically the main bursa structure is the subacromial bursa which sits between the rotator cuff and larger deltoid muscle. It’s a fairly large structure and is commonly involved in impingement issues (will talk more in later posts).

Briefly returning to the bones of the shoulder complex, the humerus and scapula meet one another at an area called the glenoid. The head of the humerus (which is round) sits within the glenoid cavity (which is quite small and shallow) and thus is known as a ball and socket joint meaning we have movement in all areas (forward, back, to the sides and in rotation). A round thing on a fairly flat surface tends to not be very ‘stable’ – a football on a table for example can go anywhere which isn’t too good when we’re looking for things to stay together. This is where labrums are important. A labrum is a piece of cartilage which is fibrous in nature. In the shoulder, this structure sits within the glenoid cavity and encircles the head of the humerus which allows for the joint to become a little deeper and thus a little more stable. The tendon of the long head of the bicep actually attaches within the labrum as well providing it with another layer of support. Think of the labrum as a washer for a screw – it seals the two sides of the joint together.

Don’t forget – your skin is a piece of connective tissue as well and we need good mobility of the skin to assist with human movement. If you have a scar for example your skin and therefore movement in general will be restricted within this region.

So, there you have it! A brief overview of the anatomy of the shoulder. There’s a heck of a lot of stuff in there which all has the possibility to be injured. Next week we will be looking at what the common issues are and the final part of the trilogy will be treatment methods and the evidence behind them.

There’s a lot of information in here. If you need any further info or have any questions drop me a line =]

Speak soon!

 

*please note that this series is for information purposes only. Should you be experiencing issues with your shoulder, or any joint in general, please contact a relevant healthcare provider for accurate assessment, diagnosis and treatment

Are we over-controlling control?

I’m sitting here having a drink and looking out at the rain pondering whether we over-control control when it comes to human movement.

I recently attended a really interesting symposium put together by the ACPSEM, IADMS and the University of Edinburgh on Control in the Artistic Athlete. Firstly the obligatory thanks for having me there to learn from great speakers at a great event. It was a great (can you tell I thought it was great) opportunity to network with people working in the same field as myself as well as share ideas and thoughts with one another. Now that the formalities are out the road it’s time for my take on what we learned over the weekend in a nutshell.

Let’s talk hyper mobility (or it’s PC term – hyper laxity) to start. Sure, this can pose a host of issues but does it serve a protective purpose as well in certain scenarios? For example, if you’re a Gymnast working on head balances then surely an element of hyper mobility aids the overall aesthetic of the pose? Whether we like it or not there’s an element of ‘nice on the eye’ when it comes to sports such as gymnastics, dance and diving and these groups are scored by the judges at all level of competition on how things look so surely being hyper mobile would aid progression through the ranks. This was a hot topic and the answer was a unanimous yes – it is protective and it is advantageous in these scenarios.

But why? Well, from the athletes themselves, when they finish competing in the sport they’ve been participating in for however many years they can still bend forward to pick things up, they can get up from the floor without groaning and they can lead an active life in comparison to their peers (unfortunately I have no formal literature to back this up – purely anecdotal evidence from the conversations we had on the day – shoot me!).

Remember – hyper mobility does come with other issues. Some examples:

  • Susceptible to tendinopathies
  • Loose, stretchy skin
  • Stretch marks/scarring
  • Skin discolouration
  • GI tract issues
  • Obsessiveness
  • Heightened risk of anxiety and depression

These need to be managed appropriately by the medical team during an athletes career or if you aren’t an athlete chat with your GP and Physio who can put a good plan in place for you – MDT all the way!! We need an element of control here because there is a heightened risk of injury to this client group. But, at what point do we overdo it?

It was great hearing from Lisa Howell and Shelly Power who both agreed that human’s are made to move and we spend far too long overcomplicating movement. We were meant to crawl and play and roll around in haphazard ways. As we age, grow, mature and develop we somehow lose this. We, and by we I mean Physios, movement teachers (this includes you PTs!) and healthcare providers, are constantly telling people they are moving ‘wrong’ but what is right? For example, if you stand and just swing your self from side to side. Try it now. Let your arms swing across your body, keep your feet on the ground and rotate from the waist. How does that feel? This time, brace your core, suck in your pelvic floor (everyone talks about the pelvic floor all the time so it must be super important and squeezed all the time right?), stabilise your shoulder blades, don’t forget to breathe! and do the same movement. What does that feel like now? Restrictive right! Too much in the way of instruction as well – it’s become complicated, it’s become instructive and it’s way less fun!

In my opinion, I think we need to think about movement as a whole. If someone has an injury we need to find ways for them to move that are safe but fun and challenging. We also need to ensure they understand natural healing times but are able to stay active during this time. Take total weekly work load in to account when thinking about the training or rehab programme we put together for the person – and yes work load includes work, home life, lifestyle, rehab, family life and social life. If you’ve got a hard session Wednesday night and double PE Thursday morning we might want to rearrange that hard session Wednesday night. Likewise if you’ve been off work through injury and have been working out or rehabbing then when you return to full duties we’re going to have to look at reducing your rehab load because guess what – you’ve just increased your weekly load by about 70%!!

Mobility should be looked at – effectively control through movement – and weight added to progress and overload the structures. Most importantly though. More than anything else. HAVE FUN!!!!!!!!

We love to overcomplicate things in healthcare and health and fitness but remember – we move every day and, if we are lucky enough, have been able to move for our whole lives. Start having fun again. Make it simple. Explore movement with curiosity and intrigue and see where you end up. You might just find it’s the best thing you do!

I always love having a chat with people and gaining new perspectives as well as answering questions (even if I don’t know the answer I’ll go hunting for it!). Shoot me a message through the contact page if you have any comments on this.

Speak soon!
H =]