The Seven Secrets to a Pain Free Shoulder was published by Dag Ronhovde in 2012

7 secrets to a pain-free shoulder
.
Written by
Dag Ronhovde
M.C.S.P, M.C.P.A
Registered Physiotherapist
www.BayviewPhysio.com
Copyright Dag Ronhovde
2012

7 secrets to a pain-free shoulder
Introduction
This book will give you 7 super tips, which will revolutionize the way you
treat your shoulders. Shoulder pain is a very common complaint and I see a lot of
clients with shoulder issues in my physiotherapy clinic.
My name is Dag Ronhovde
and I have been a Registered Physiotherapist for 26 years and have my own
private practice in Nanaimo, BC. Bayview Physiotherapy.

While working in stroke rehabilitation with clients that due to a brain trauma lacked strength and control over their shoulders I realized the importance of good muscle control.Often I would see clients with shoulders where the muscles were wasted and did not offer any support of the shoulder joint and subsequently the joints were
separated and subluxed (partially dislocated) in a downward direction due to the lack of muscle tone (regular muscles keeps themselves in a state of being semi- contracted at all times and this supports and keep the joint
in place).
When I started in private practice I saw people with shoulder injuries exhibiting similar problems, as
pain is a very strong inhibitor of muscle activation. The weakness and lack of proper recruitment can often be caused by injuries and can cause further damage if left unattended.
When there is a lack of proper control and the timing of the muscles are off, the joint is not able to move
within its intended trajectory.
Some of the other muscles will over power the weak ones and cause an uneven pull. This compensatory mechanism is often the reason why injuries do not heal as fast as they should. With this book I
will show you how to detect this problem and provide you with my secret techniques to fix this.
The shoulder joint is inherently very unstable, which allows for plenty of mobility.
The socket of the shoulder joint is called the Glenoid cavity and it is really
shallow. If you can visualize a golf T and the ball sitting on top of the T, this is about the same relationship our shoulder joint have with the Glenoid cavity.
So what is it that keeps the shoulder together? The most important
structures in the shoulders are the muscles
. The tendons attached to the shoulder bone keeps the shoulder joint closely packed into the socket and
they are collectively called the Rotator Cuff muscles
.
The Rotator cuff muscles act as dynamic ligaments as they ensure close approximation of the
Gleno-humeral head and the Glenoid cavity(socket) during movement. Another important structure in the shoulder joint is theGlenoid Labrum, which acts as a stabilizing “rubber”gasket around the Glenoid
cavity, and prevents an excessive forward glide.
The ligaments to the front of the joint support and prevent a forward glide and impingement of the humeral head.
The capsule of the shoulder joint is normally fairly lax and does not hinder motion much. (With capsulitis & frozen shoulder there is restricted motion due to capsular contraction, which can take a long time to recover.)
There is another factor that helps the stability of this joint and that is the cohesive forces between the head of Humerus and Glenoid cavity.
The synovial fluid act as an “adhesive”that keeps the head sucked into position during motion. The effect is similar to having two plates of glass with oil between them, which will make them stick together, and makes it hard to separate. The shoulder joint sometimes loose this cohesiveness and ligament
stability due to injuries. The advice in this book will help you correct this.

Posture

The position of the shoulder blades affects the alignment of the shoulder socket (Glenoid cavity) and normally the shoulder blades should be about four fingers width apart. With rounded shoulders the shoulder joint is rolled forward and this increases the risk of impingement to the front and also under the sub acromial arch.

The Acromio-Clavicular joint can also be compromised if the shoulder blade is not kept in a proper position. Especially reaching across (Adduction) will cause strain and pinching of the AC joint if the shoulder blade is in the wrong position. Most of us are unaware that the posture we use may be incorrect and harmful, as most of us do not seek help until we experience pain. I saw an interesting poster with an x-ray view of a person sitting in an office chair and typing on his computer with a terrible posture. The title said ” Spinal injury at zero miles per hour! “ I am sure this poster was a surprise to most people, because
how can we hurt ourselves with sitting still? Poor posture habits create changes to our soft tissue i.e. muscles, ligaments and tendons become over stretched and lengthened.

The lack of proper tension in our tissues affect the alignment of our joint surfaces prior to movement and thus we are more at risk for strains and pinching which leads to pain. Pain in turn affects the ability of our muscles to activate properly. So how can we change our posture? It can be difficult initially as the sensor organs that normally would let us know when we are wrong have been re-programmed and can’t be trusted. We have to use different strategies such as visual cues through mirrors or videotaping. By practicing good posture on a daily basis we can change and attain a better and stronger body.

Lock and Load

This technique was named by one of my clients after I showed her the action of this exercise and I have used the term ever since. The technique is universal for the whole body at every joint we have. It is one of the most important and effective techniques you will ever learn. What often happens in our joints is that we overstretch & overreach ourselves and by doing so leave our joints vulnerable to injury and pain. There is a simple way to avoid this by being more positional aware and correct the joint positioning prior to initiating movement.
An example is when we carry a heavy shopping bag the joint will be stretched in a downward direction and when we put the bag down there is often latency where the joint remains outside its normal position. If you then move the shoulder into flexion or abduction before the joint has had time to return to its close packed position you may feel a strain or pain.

Pulling your shoulder blades back into a V shape is the neutral position, which I call the “Lock” phase and then visualize the shoulder joint being sucked into its socket “Load”. Once this has been done the joint is ready for motion. The key to master this technique is repetitions, so practice whenever you move your shoulder and you will experience results a lot faster.

Dynamic Muscle Stability

Muscles tend to work in teams and in this way they can provide stability as well as mobility. Just imagine if when bending your arm the opposing muscle Triceps did not activate? Your arm would bend too fast due to lack of control, as the Biceps would exert a powerful force of flexion (bending arm) with no force to dampen the motion. The Triceps would normally give way in an eccentric manner and provide tension and guidance to the motion.
Around the shoulder joint and shoulder girdle it gets a bit more complex as there are more muscles involved in fine-tuning whatever movement you choose to do. The shoulder girdle includes the scapula and collarbone as well as the shoulder joint and they all need to play as a team to ensure proper motion pattern.

With Dynamic Muscle Stability exercises the focus is on the timing of recruitment, which means that each muscle has a role to play, and needs to activate at the exact time its needed. The principles of Dynamic Muscle stability are as follows.

1. TIMING AND SEQUENCE OF ACTIVATION

2. QUALITY OF CONTRACTION

The timing is very important as there are set points through the range of motion where the prime moving muscles should activate and the sequence pertain to the fact that in some cases one specific muscle activates first and then followed by the other muscles for a nice smooth movement. When all the muscles work together in a synergistic way the joint is less likely to cause
excessive strain or pinching which is usually the origin of pain and tissue damage.

Rotator Cuff strengthening

I have found that using a Theraband (elastic exercise band) to be very useful in rehabilitation as it is easy to take with you anywhere. There should therefore be no excuse for not doing your exercises.
I read a study done on shoulder dislocation and how the use of EMS

Electric Muscle Stimulation could help improve shoulder stability by activating specific muscles. I found this very interesting, and my idea evolving from this was that Active Recruitment of these shoulder muscles would be more powerful. So instead of putting on electrode pads and stimulate the muscles in a passive way I propose to use a Theraband to activate the same muscles.
Over the past 22 years I have had great success with this so I believe my hunch was correct. To keep the shoulder joint central in the socket while moving the arm is the goal and this can be difficult if the tissues around the shoulder has been overstretched and lengthened. As mentioned before, our muscles play a very important role in stabilizing the shoulder. By activating the external rotators of the shoulder: Infraspinatus, Teres Minor & posterior Deltoid the joint is retracted back into a better position for movement.

I developed a system with the use of the Theraband were you can activate the above muscles all at the same time. The first part of the exercise is to have the shoulder blades in a neutral position “lock and load”. The second part is to keep the elbows by your side and pull the rubber band outwards. If the shoulder is too sore you can use a rolled up towel under your armpit and keep the arm stationary while pulling with the good one. In this manner you can create an isometric muscle contraction, which is also beneficial for the external shoulder rotator muscles. The progression to the above exercise is to attach the middle of the rubber band to a stationary point and do the push out and pull back at the same time to ensure recruitment of the posterior stabilizing muscles in the shoulder joint. I usually recommend doing these exercises 2-3 times per day with 10-20 repetitions and starting with 1 set for the first week and then progress to 3 sets over the next few weeks. This exercise is excellent at re-activating the shoulder stability through motion.

Range of motion exercises

Often when a shoulder injury is causing a lot of pain, most people tend to avoid movement of their joint. The worst thing we can do to any injury is to totally immobilize it as the tissues that needs to heal needs nourishment but with lack of motion this is hampered.

I am a firm believer in Active Rest where some movements and gentle isometric muscle contractions start early on following injury. This helps to ensure proper blood flow and nourishment of tissues that are working on healing. Encouraging early motion can prevent the “neuromuscular” inhibition, which causes muscle weakness and imbalances.

A study was done on doing gentle isometric exercises for Quads following knee surgery, and they found that the group that started right away was able to prevent the onset of muscle inhibition and therefore returned to sports and normal activity faster and with fewer complications.
For shoulder injuries it used to be popular to prescribe “Pendular” exercises (arm dangling down and performing circular motion), which I rarely use as the traction force with the arm hanging causes a disconnect and does not promote normal activation. The other exercise I have stopped prescribing is the shoulder pulley, as the motion does not focus on normal controlled motion but more on how far you can go. Too often I see people doing this exercise and allowing the shoulder girdle to elevate up to their ears with the shoulder blade swinging out with no control, which is no good if you want to regain function.
I prefer to use a Gym ball that can be used to roll on a table and progress to roll up the wall. The benefit of using the ball is that even with a fairly recent injury you will be able to move the shoulder with the support of the ball in a non-gravitational manner. The movement pattern also mimics the normal movement and recruits the same muscles thus preventing the loss of muscle functionality.
Exercise number one on the table aim to move the shoulder into 90 degrees of flexion. An important fact to remember is that you want to avoid movement of scapula such as elevation or protraction of the shoulder girdle. Also avoid overreaching, as this is not a normal movement pattern and can lead to discomfort and pain. Rolling the ball on the tabletop can also be done in a slightly sideways position into Abduction. Again with this motion do not elevate the shoulder blade prematurely, as this will cause impingement of the top of the humeral head. When the sideways motion (Abduction) is causing pain due to impingement of the Supraspinatus area you can try to push down on the ball while doing this motion and this will usually help to activate a downward glide of the humeral head which eliminate the pain.

Once you are ready to progress to more range of motion you can use the ball to roll it up against the wall. An important factor to remember is that the shoulder blade stays put until you reach 90 degrees of flexion, after 90 degrees there is a natural motion of the shoulder blade where the lowest part moves outwards. Still, the shoulder blade should not elevate, protract (move forward) or abduct (move sideways) too far as this would interfere with the natural biomechanics of the shoulder girdle.
Excessive unnatural motion creates compensatory muscle activation strategies so they should be avoided. It is therefore imperative that we focus early on to create the best and most natural movement pattern in an effort to prevent new bad habits.
I believe that integrating the proper movement strategies into daily living can help to speed up the process of acquiring a perfect and pain free movement pattern.
Another important exercise to master is to push the ball against the wall as this helps to ensure proper strengthening of the Serratus Anterior which is a muscle that originates from under the shoulder blade and attaches to the ribs on the side of your rib cage. Its function is to prevent excessive winging of the shoulder blade during movement and helps with the stability as the shoulder goes beyond 90 degrees of flexion. By pressing against the ball like a push up, but with the elbows fully extended you aid the recruitment and strengthening of the Serratus Anterior and the Rotator Cuff muscles. The pressure also facilitates a backward glide of the humeral head and helps it to return to its normal position. The movement and compression of the shoulder joint surfaces stimulates the production of synovial fluids. By improving the amount of available synovial fluid we promote nourishment and cohesiveness of the joint surfaces, which help improve the stability.

When the tissues around the shoulder have healed and are not causing pain you will be ready to perform the same movements without the aid of the ball.

Taping and bracing

I often use tape to help facilitate a better positioning of the shoulder girdle.

The tape goes from front to back mimicking the action of the Lower Trapezius muscle. By ensuring the scapula is supported in a neutral position it is easier to move the shoulder joint. Another taping technique uses tape to support the humeral head in its socket and counter act the gravitational pull on the shoulder joint. Using tape to pull the humeral head backwards thus assisting the external rotator muscles can be used in combination with the above techniques. Studies have found that by facilitating the activation of the shoulder muscles you can speed up the healing process and overcome the effect of neuromuscular inhibition. Some people may be allergic to taping and in this case a shoulder brace may be appropriate, to fulfill a similar effect.

Functional Dynamic movement acquisition

Once sufficient healing has taken place and there is no pain or weakness present, the rehabilitation should still continue to ensure that proper re-programming of the shoulder has taken place. Proper functional movements require a finely tuned repertoire of coordinated effort of all the shoulder joint and shoulder girdle muscles. I usually encourage an integration of functional movement practice at home. This includes simple tasks such as putting plates and glasses up into the cupboard in a specific sequence. The secret of doing this exercise is that it has to be performed with attention to the accuracy of motion.
In this way the end result will be a perfect motion pattern which provides protection to the shoulder joint by preventing a faulty pattern which if unchecked could lead to secondary injuries.
People are often surprised when their shoulder pain returns for no reason. The reason for the recurrence has a simple origin, the motion pattern they got used to after their injury lacked perfection and thus impingement and strains reappeared. As well as the above simple involvement of day-to-day activities I suggest some simple exercises using a medicine ball while lying on your back and in standing to practice movement while being compressed. This helps to stimulate the activation of the rotator cuff muscles and also aid in the positioning of the humeral head.

Conclusion

It is my hope that the above information has been useful for your shoulder problem. If you have any questions or comments, please contact me through my website www.bayviewphysio.com.
The above techniques are the ones I personally have used for the past 22 years as a Physiotherapist with great results. Good luck with your journey of self-discovery and self-healing and bear in mind that what you may have been taught before is not necessarily wrong, but these techniques are high quality and if you give them a go you should see results.
As usual please check with your Physician before embarking on any exercise program to make sure you are not aggravating any underlying problems. As these exercises are very gentle I do not foresee any problems with them, but make sure you listen to your body as an increase in pain is counter productive, so please stop if you feel any aggravation of your pain. Slow down and focus on your motions and enjoy, your shoulder will improve faster that way.

Yours truly,

Dag Ronhovde
Registered Physiotherapist