Rotator Cuff Tendonitis/Tear

The most common musculoskeletal complaint in chiropractic and orthopedic practices is back pain. The second most common is shoulder pain. The most infamous injury of the shoulder is injury to the rotator cuff. The rotator cuff is comprised of 4 muscles attaching from the scapula (shoulder blade) to the head of the humerus (the large bone of the upper arm). The 4 rotator cuff muscles are the supraspintaus, the infraspinatus, the teres minor, and the subscapularis. The diagram below shows the orientation of the rotator cuff muscles. (anterior=front, posterior=back)

The supraspinatus controls initiating the elevation of your arm out to the side (the first 30 degrees). It also stabilizes the shoulder when your arm is elevated at 90 degrees (held directly out to the side). The main action of the infraspinatus is external rotation of the shoulder (think when a pitcher cocks his arm back during a throw). It also stabilizes the posterior aspect (or back part) of the shoulder. The teres minor assists the infraspinatus in its actions. The subscapularis, the only muscle on the anterior aspect (front part) of the scapula, internally rotates the arm (think when the pitcher follows through his throw).

Rotator cuff tendonitis is inflammation of the tendons attaching the muscles to the bone. It usually occurs due to overuse or repetitive trauma. Simply put, it is an irritation of the rotator cuff tendons causing pain and/or weakness of the shoulder. Rotator cuff tears are a more serious condition. Partial-thickness tears of the rotator cuff muscles are divided into 3 categories: grade I, grade II, and grade III, depending on the severity of the tear. A full thickness tear is just as it sounds - the muscle is completely torn and detached.

A hallmark symptom of rotator cuff injury is shoulder pain during the night, especially when lying down to sleep. Rotator cuff injury is often caused by overuse during overhand motion, such as throwing a baseball or freestyle swimming. However, this injury is not limited to athletes. Many people can develop rotator cuff injuries by seemingly insignificant motions that damage the tendons over time.

So how does this fit into the chiropractic picture? For one, an orthopedic/sports chiropractor can properly diagnose your shoulder injury. Depending on the severity of the injury, some conservative care can be utilized to facilitate healing and strengthening of the damaged rotator cuff. Some physiotherapy modalities, such as the cold laser, aim to help speed up the recovery process. However, in order to prevent too lengthy of a blog, I will not go into detail how these modalities function.
Chiropractors do excellent work when looking at the shoulder as only a part of a piece of the movement lever. The rotator cuff muscles are only a part of what's known as the upper extremity kinetic chain. From a physics standpoint, whenever you move your shoulder, there is an energy transfer that travels from your core, up your back, across your scapula and first rib, into the shoulder, and down your arm. However, the kinetic chain should be a topic discussed completely on its own.

Your orthopedic/sports chiropractor is well qualified to examine and treat your rotator cuff injury. Conservative management of rotator cuff tendonitis/tears have shown to be successful in eliminating pain, strengthening the involved structures, and returning athletes and others to normal activity. Depending on the severity of your tear and activity status, you may be referred for a surgical consultation. However, surgery should not be your first option. It is possible to heal your injury before a surgical intervention is required. Ask your orthopedic or chiropractic physician about conservative management for your shoulder.

Disc Herniation

Let's begin by discussing the big 3 in orthopedics: disc herniation, rotator cuff tendonitis/tear, and ACL injury. First on the table is disc herniation. Let's face it; as a chiropractor, this is my bread and butter. Unfortunately, many people still do not think to visit their chiropractor for their disc problems. To begin this lesson, let's learn a little anatomy.

The disc, more appropriately known as the intervertebral disc, is the cushion that sits between each vertebra in your spine (with the exception of the top 2 vertebrae). Each disc is composed of 3 segments: the vertebral endplates (which border the top and bottom of each disc), the nucleus pulposus (the center that acts as a fulcrum for movement between the vertebral segments and absorbs fluid and nutrients to keep the disc healthy), and the annulus fibrosus (the fibers surrounding the nucleus that make up the majority of the disc).

Disc herniation (or disc bulge) is when fibers of the annulus protrude from their normal anatomical limits. If protruding back, it can cause irritation to the nerve roots or, in more severe cases, compression of the nerve itself (pinched nerve). It is important to note that a disc herniation does not equate to a pinched nerve. In some cases, the presence of the disc in the epidural space without mechanical compression can cause nerve root inflammation and even irritation to the dorsal root ganglion, which processes sensory information entering the spinal cord. In all cases, sharp pain may radiate down an extremity (think sciatica) along with numbness and tingling, loss of sensation, and/or positional relief.

Several factors may lead to disc injury. Trauma is the most noticeable process of injury. However, in many cases, microtrauma can weaken the disc fibers, leading to an insignificant event that causes a sudden onset of symptoms (i.e. I bent over to pick up my kid and heard a pop, then ouch!) Microtrauma occurs from improper movements that put additional stress on the disc. Symptoms are usually absent or minimal until the disc is so weak that a sudden herniation occurs, resulting in intense pain.

Diagnosing a disc herniation is dependent on symptoms and orthopedic testing. Pain down your arm or leg does not necessarily mean you have a disc injury. Orthopedic testing is the most effective way to determine disc injury. It is important to note that the only imaging method to diagnose a disc herniation is by MRI. Discs do not appear on an x-ray film; therefore you cannot diagnose a disc herniation by looking at an x-ray! It frustrates me to hear how many people say their doctor diagnosed their x-ray with a disc injury... in some cases you can suspect herniation but ortho testing or MRI is the ONLY way to properly diagnose this condition.

There are many different treatment methods that chiropractors utilize for herniated discs. The chiropractic adjustment is the staple of chiropractic care. In disc injury, the adjustment restores motion to the vertebral segment that is affected by the disc injury. By restoring motion, the adjustment allows for a process called imbibition to take place. Imbibition is a physiological process in which fluid and nutrients are absorbed back into the disc. When a load is applied to the vertebral segment (such as in movement), water is lost in the disc, but electrolytes such as sodium and potassium remain. When the load is removed, rapid rehydration of the disc occurs due to the electrolyte concentration. In disc herniation, this fluid motion of the vertebral segment is interrupted and the load remains on the disc, preventing the rehydration mechanism. Mechanical decompression is also a treatment used in many chiropractic offices that simulates the process of imbibition. Mechanical decompression removes loads on the disc for an extended period of time, allowing for more rehydration to take place. This process is repeated over a period of time to speed up healing.

Your chiropractor or orthopedist may also give you specific exercises to perform as you recover from disc herniation. The purpose of the exercises is to strengthen the muscles supporting the spine, in order to prevent future injury. Talk to your chiropractic or orthopedic physician to learn more about disc injury and how to prevent it with proper ergonomics and stability exercises.

Choosing the Right Sports/Orthopedic Chiropractor

Before we begin on orthopedic injuries, I realized that I should first discuss a crucial topic; how to choose the proper sports/orthopedic chiropractor. Let me begin by asking a simple question - would you trust your gastroenterologist to deliver your baby? Would you let your OB/GYN manage kidney disease? The answer is obvious: of course not. It's not that they aren't great doctors, they just haven't specialized in that particular field. Their expertise lies elsewhere. In the same sense, you should seek a chiropractor with the proper credentials to treat your orthopedic injury. Like most medical physicians, chiropractors can gain additional training to broaden their expertise. There are many different ways to recognize that your chiropractor has received the proper training. The CCSP, or Certified Chiropractic Sports Physician, is a certification program that trains chiropractors in sports injuries. However, this is a chiropractor-specific certification. Some chiropractors obtain a CSCS, or Certified Strength & Conditioning Specialist certification, which is more widely recognized outside of the chiropractic field. While this is a more exercise based program, it is a popular certification for chiropractors who desire to work with athletes. Some chiropractors obtain a Master's degree specializing in exercise, sports, and rehabilitation, which is also a path to gain recognition outside of the chiropractic field. A chiropractor's background may also help give them experience in orthopedic injuries; some chiropractors are former athletic trainers (ATC), personal trainers, or physical therapists. Whatever the background or training, it is important to verify that the experience is there.

It's as simple as asking your chiropractic physician what his or her experience is with orthopedic injuries. They should be able to tell you any certifications or seminars attended relevant to orthopedic injuries. Another important factor is their relationship with the medical and/or orthopedic community. Should your injury require, your chiropractor should not be afraid to refer you for surgical consult. As much as we try to prevent or delay surgery, in some instances it may be the best option.

First Entry

Welcome to Orthopedics & Chiropractic! This blog is meant to provide information regarding certain orthopedic injuries; what they are, how they occur, and how chiropractic may be able to help. My experience interning at an orthopedic clinic showed me that majority of the population has little knowledge on orthopedic injuries; even fewer know that chiropractors can treat many injuries that do not require surgery. The important thing to remember, whether a patient or physician, is that chiropractic care for orthopedic injuries is not meant to replace traditional medical care. It is meant to co-manage an injury in order to prevent surgery, speed up recovery, and return the patient to optimal health.

The next blog will begin the information on specific injuries. If there is anything in particular that you would like to ask or learn about, feel free to e-mail me your questions and requests.

"The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease."
~Thomas Edison