Labeling yourself into a shoulder box Bullet Proofing your shoulders or just plain “Bull…t?” Why templates don’t work Envy is the worst enemy Great Expectations Double Crush Syndrome More than 80 different types of junctions, muscles, ligaments, nerves, artery, capsules that can affect the shoulder. Don’t knock Intervention Pain Management. They can help speed up recovery by half the time. Cupping vs Blood Letting Cupping vs Placebo Ultrasound = Collective Silence Active Release Technique is not Pinning and Stretching
Yeah. It’s not always one or the other. You can have the mobility without instability that leads to injury. You can’t have stability with not enough mobility that leads to injury too. And it’s finding the sweet spot. People usually always classify themselves into one category. So they’ll spend most of their time yeah, so yeah, I need to do more overhead, stable stability, and I think I’m lacking overhead mobility. So what happens if you actually do get into mobility you get that you don’t have the strength to support that new reach that you’ve just developed. So I find people get caught up in the one or the other, especially with all of the trends that go through, you know, like raw mod or mobility what all the different words I come from a CrossFit background in case you haven’t noticed yeah,
but because it is a online and template kind of thing. Unless you’re willing to switch on yourself knowing what exactly you need to do, going through the whole gamut, yeah, you might get better stronger shoulders, but you might not be addressing the underlying issue, which I guess from what we’ve seen is usually muscle pathani stabilizing this gap, you allow movement of the shoulder, so that’s the scapula can be quite subluxed.
so that’s meaning that it can sit row high above or very far below or to the left or to the right. Either way, sometimes those things can be triggered by either a accessory enough a long thoracic nerve, it can be a nerve issue, and a nerve and bone issue or articulation issue as compared to just musculature all that is compensating so much from the chest or pecs or into the jaw or into the neck or into the head and one of those things that is creating that alteration. So when it comes to template exercises, it’s really easy to give template exercise. Anyone can do that. But it’s like, it’s almost like, you know, you try cutting your own hair. If you’re not a guy and you’re wanting to, you know, just not using number one or number two, just shave the whole thing off. And you want a really good start. It’s really hard to get a good need to be your own stylist. It’s impossible. So when that happens, that becomes my pet peeve in mobility and similarly, because a lot of times people will not be able to tell when hey need mobility when they need stability, and sometimes it changes have weight when that happens and what was going to do them are they going to suddenly going, oh, I need mobility in this shoulder joint but I need stability in that shoulder and what’s gonna happen to my clinicals wise what’s gonna happen to my forex.
Dr Shermain Wong is a seasoned chiropractor with particular expertise in Sports Medicine and a passion for the benefits of in ‘Active Release Technique™ (an advanced Soft Tissue Technique developed by Chiropractors). She is professionally trained in ART and has a Masters in Clinical Chiropractic from RMIT University. Dr Wong has provided chiropractic and movement rehabilitation services at international sporting competitions, and provided rehabilitation and training for professional dancers, professional football players and professional athletes.
She can be found at https://www.jurmainehealth.com.au/dr-shermain-wong/
Episode 003: Shoulder Issues Part 2
Podcast brought to you by Jurmaine Health
This is Jurmaine Health, the center to help you achieve wellness in both your brain and body. We endeavor to encourage cross communication between health professionals for your health and well being. We bring you topics on neuro psychology, neuro behavior, neuro musculoskeletal, neuro gastro, movement is well being, metabolism and microbiome, which are also some of the services that we provide. Today we'll be speaking to you about your shoulder stability and mobility, musculoskeletal injuries, commonly used assessments for the shoulder and the different types of treatments that are available out there. This will be part two of our shoulder series. And joining me today, we have got Dr. Sherrmain Wong and our beloved physio Cera Lai.
Thank you, Jackie.
Good morning, everyone. Today, we will talk about shoulder mobility and stability. And what we see and people who are doing too much range of motion type, too much range of motion type exercises, too much stability work, overly doing stability work and not getting a result. I'm sure that I'm not the one who has seen this happen in our clinic and maybe other people's clinic too, I'm not sure. But what we see is that it's really easy to just place people on a rotator cuff exercise template. Yeah, that's right. So the best person who has a history of understanding why people will keep doing internal and external rotation would probably be Cera. So Cera, would you kindly explain to us why it's always the case.
I guess in terms of conventional form of assessing pain
You go through your rotator cuff strength and all the planes and invariably you'll find that it's either the external rotators or the internal rotators will have quite a big discrepancy. I guess that's why the go-to exercise, you treat what you're firing, so they find that. So that's what they treat but from personal experience I find that that's not enough because they don't actually test and see why the pain comes on in the actual movement that brings about the pain
And Jackie what do you find?
I agree with Cera. So most of the time, you just hear people coming in with a pain let�s just go motions. So most we've seen people and a lot of our patients are the same, as we know we're one of the last ports of call. So we've seen people we usually, see people after they've seen physios and chiropractors. Just a mix of everyone and we�re usually the last guys. Since I've got a rotator cuff injury, okay, cool. Which muscle, what do you mean? Which muscle? So guys, there's like four muscles in like the rotator cuff. What am I dealing with? They say I�m just told that it�s rotator cuff injury. So this was the exercise that I was given.
So and then when I see, usually half the time, it's not even a rotator cuff injury, like it's actually muscles support that support the rotator cuff. They're probably the primary influencer in this whole issue. And they've been doing exercises to just support the rotator cuff. And it's like, well, cool. Now you just destabilize both shoulders and then your other shoulder is not much better than your supposedly bad shoulder.
Guys now I have to just rebuild it from scratch. And you just go okay, cool. Can you not do those exercises that you were given? And let's give you a whole bunch of new things to do. A lot of the time again, like we're saying, sometimes they'll to destabilise one shoulder, and then you'll be looking at the other shoulder and I can barely move it but they've worked on it to the point where they're thinking it's stable but it also is telling me they've pretty much just limited the whole motion.
So instead of being stable, it's restricted and hypomobile. Hypo mobility means that it doesn't move very well. It actually is not moving well enough. But what people think that by not moving very well, it's stable.
And it's and that the other one's unstable.
That's correct. Yes. Do you find that true? Or not in your experience yet?
Well, I always view stability and mobility as a spectrum.
Yeah. It's not always one or the other. You can have the mobility without instability that leads to injury. You can't have stability with not enough mobility that leads to injury too. And it's finding the sweet spot. People usually always classify themselves into one category. So they'll spend most of their time yeah, so yeah, I need to do more overhead, stable stability, and I think I'm lacking overhead mobility. So what happens if you actually do get into mobility you get there where you don't have the strength to support that new reach that you've just developed. So I find people get caught up in the one or the other, especially with all of the trends that go through, you know, like raw mod or mobility what all the different words. I come from a CrossFit background in case you haven't noticed yeah, and then with like the active life RX guys coming in
What is that?
So they are movement company started by chiros that comes out with programs like bulletproof shoulder program, that kind of thing. So they give you it's a prescription kind of program where you buy the program.
but because it is an online and template kind of thing. Unless you're willing to switch on yourself knowing what exactly you need to do, going through the whole gamut, yeah, you might get better stronger shoulders, but you might not be addressing the underlying issue, which I guess from what we've seen is usually muscle stabilizing this gap, you allow movement of the shoulder, so that's the scapula can be quite subluxed.
so that's meanin,g that it can sit very high above or very far below or to the left or to the right. Either way, sometimes those things can be triggered by either a accessory nerve a long thoracic nerve, it can be a nerve issue, and a nerve and bone issue or articulation issue as compared to just musculature all that is compensating so much from the chest or pecs or into the jaw or into the neck or into the head and one of those things that is creating that alteration.
So when it comes to template exercises, it's really easy to give template exercise. Anyone can do that. But it's like, it's almost like, you know, you try cutting your own hair. If you're not a guy and you're wanting to, you know, just not using number one or number two, just shave the whole thing off. And you want a really good start. It's really hard to get a good need to be your own stylist. It's impossible. So when that happens, that becomes my pet peeve in mobility and similarly, because a lot of times people will not be able to tell when they need mobility when they need stability, and sometimes it changes half way. When that happens and what was going to do them are they going to suddenly go, oh, I need mobility in this shoulder joint but I need stability in that shoulder joint and what's gonna happen to my, what's gonna happen to my thorax
and where is it going to go you know,
So that is my pet peeve with �.
My other one is everyone comparing themselves to another person.
What do you mean?
Especially if they go to a gym. So they'll see one person's got range that goes excessively over their head
Because that might be that person's actual range and their mechanics and another person does not have anywhere near that range. But again, it's their build their structure is nowhere near and then I need to get my shoulder so mobile, that I reach the other person, guys, like everyone has like there's a specific range. Even for assessment, there's an actual range, it's not one specific degree. That's a normal, say, bringing your shoulder outwards, bring your shoulder up, it's not just one it's a range of degrees. And that's normal. Putting yourself comparing yourself to one person, that�s got that full range of versus that you that's still within that range.
That's normal alright. Try putting yourself to the excessive when your body's not capable, but it's not your actual build. It's not your musculature capabilities like voice capabilities, full stop, no matter how hard you try to push it, you'll end up just damaging yourself whether it's tearing ligament tearing your muscle, anything of the sort, you cause damage to yourself just by comparing
Problem is because we have movement standards, and that's what people try to achieve. But they don't acknowledge that they're just not there yet.
Movement standards. So I think that there's a quite very strange, while in my mind, very strange perceptions of range standards, versus what is functionally useful for a person. It's quite different and how they're getting there is quite different too, because like our previous podcast if you have listened to it if you haven't listened to it, okay, and then
please go back and listen to it.
Yeah, that's right podcast one shoulder one, part one. And you will hear that one with one of the case studies, the shoulder issue is a hip-related issue, hip-related mobility issue that locks the shoulder down. So listen to that. And then decide what you want to do with your mobility, excessive mobility, excessive stability and what was it? If you don't know, give us a call. Yes. And the next thing we're going to talk about relating very closely relating to this is musculoskeletal injuries. Yep
Yeah, double crush. Nerves being cool to different areas or it's not.
referred pain into either the wrist.
While the hands are wrestling, they'll start feeling it.
And I think usually it's the other ones around the chest, isn't it?
I don't know.
Well, depends on where the other crushes I should say,
Yes. So it's like is it like a medium nerve entrapment? Or is it like carpal tunnel syndrome? What are you referring to?
It presents itself as carpal tunnel, but anytime pretty much people start feeling numbness and tingling in their hands. They just assume it's carpal tunnel. If you're the one that most people know.
Tingling in hands. Especially the first three fingers equals carpal tunnel syndrome.
Nobody goes with the fact that it's me and it is the one that's supplying it. So
no, of course not because that's special, isn't it?
So everyone was good. All right, sweet. I've got carpal tunnel syndrome, until you start checking on until you start listening to what activities they do, whether it's sporting, whether it's lifting, or whether it's the actual work that they do, whether it is manual labor, trade work and stuff like that, then you might find alright, fair enough. It's the median nerve like we talked about, which does supply first grouping and can be caught somewhere along that whole chain all the way up.
So how many muscles are we looking at?
catch it? We are looking at least
Good, I'm looking at at least a good 82 different muscles just in the shoulder, not
catching you know, trying not to scare you right there.
But that can be the case.
It can be.
So when we are working on you, we are working very fast and very hard and trying to resolve your issues as quickly as possible 82 or more right musculature soft tissue capsules, tendons, ligaments, artery, nerves, lymphatics, all those things contribute to show that non healthy shoulder.
Yeah, a non-healthy shoulder.
When that happens, we do have got to look closely at what the trouble is. And we know we're in it quickly if it is a tear or not. So this relates what has been happening is that for shoulder issues, right. For the older generation like, I don't know if they are like 65 and above, is that older
Yes. So the fastest way to do it is... My preference and I'm what I'm like is to have them go for either an API or a PRP or a tunnel site intervention, pain management, that is from I know a musculoskeletal, GP, or a musculoskeletal radiologist because what is going to happen what happens to work we find?
This is for a tear or something like that.
Yeah. I mean, yeah, you're talking about tear, or you know, partial tear. If you think about that, that's not going to happen. But if you are talking about you know partial tear, partial is and it depends on the how bad the partial tear is. It's one or the other that I would like to refer that on for intervention, pain management, because that is the fastest way we find to resolve this issue as compared to critical as it is on shots, cortisone shots or cortisone tablets or one of those things. It's almost like 25% of the time we get a result.
Yeah, well cortisone predominantly, will just mask the pain that doesn't do anything.
And if anything neck injury works
That's correct. And also cortisone. It's just, it's anti-inflams is pretty much a new class.
That's exactly what we �.
Yeah. But um, intervention, pain management is really useful what I find to help resolve the case really quickly, in a shorter amount of time, then as compared to rehabbing over and over again. So there are people who asked me, you know, hey Shermain, why are you sending me to get an injection? Is that going to be helpful? Why can't we just rehab this through? So well, that a couple of things are going to happen one is that the quality of the tissue is not going to resolve itself and we cannot rehab it to the best tissue layout after a severe especially if the angle of the neck and affects the outcome of the treatment. So that's one. Secondly, if we are going to do if we are going to wait to rehab it's going to take like eight months, nine months, maybe a year, especially if it's a shoulder but if it's if with this intervention, pain management, what we do is to shorten the time really quickly by about
Yeah, we will shorten the time by about four months or three months. So the recovery time is mainly maybe about eight weeks, 12 weeks, and they move really well after that. So there is always a positive outcome, to some medical interventions.
Which does require surgical intervention most of the time. Most of it, most was not after they've had the surgery. What do we say? We say the same thing. PRP, API injection as well, just to speed it up even further, because the recovery is already there, that one influences more blood flow into the area, your blood gets healed up even faster.
the recovery process, we take it down even further. So as opposed to being saved in this time, post it post proper surgical, as opposed to being eight months recovery, take it down to about six months. And then with rehab
is fast, and the person doesn't stay in rehab all the time and just during, you know, rotator cuff exercises, and that is rewarding. Okay. Ultimately, it's really rewarding to see the recovery come up so quickly. I don't think you've seen that one yet.
not yet. So it needs a bit of time.
yeah. And that is when I like to speak about something else. I can't remember why I'm going to speak about other treatments. Other treatments like cupping.
Amen. Not all cupping is bad. I can't see it happening. I can't see it doing anything either. So I do agree and disagree. We were talking a couple days ago about cupping as in the heat cupping balls that some people would just go you're cupping to release set like we're talking more muscular we're feeling it's tight muscle. So they got it. They want the one ball cupping the heat one that just pulls up the �
Yes. And we all were discussing with Shermain saying whether it works or not. And I said I agree with that one. I can't see it doing too much because I haven't I've tried it on myself as well. Not to you all, I actually use myself as a guinea pig sometimes.
I do too. Yes. Usually we all do. I think we all do.
Tell you what we are like�
We did discuss this with Shermain. We decided that the heat from cupping. I did say that apart from leaving bruises on you, I can't see it really having too much of an effect. I was talking to Shermain about this the other day, I think they call it myocupping, where they've got like the little A, this is a plastic ball or a silicon ball where they pump it up sort of thing, and they move it over the muscle where it's a very tight grip, but they move it over. I actually do feel that one does do some work. So if a faschia release, at least on the top layer, that's actually not too bad. You wouldn't be going for it for a deep layer. I can't see it working too much like especially say you went for the �
No, that�s not gonna happen.
but if you're looking at the superficial muscles it's actually not too bad. You do feel one you do feel the release and then you do feel the actual ability for the muscles to slide over and the fascia to slide over. I'm going to say that cupping it's about one that I could still possibly recommend
Cera what about yourself, what you experience with cupping
I enjoy it because it's so relaxing, unlike the other forms of manual therapy, it's not painful. And if you get the warm one where they use a flame to create a vacuum instead of the plastic ones which has a pump. So, I think we call it suction cups and the glass one the warm one is very relaxing. When they do the cupping thing just feels nice and we all know like if a joint is like sore or whatnot heat generally usually releases pain.
So that's that when I was growing up the cupping. So I saw my dad getting cupping and one of those bone setting Chinese medicine ancient pipe traditional care yeah traditional care. Yeah, so they will pierce the skin. Points and the bloodletting one, and you have the suction cup over it and all the blood will be like spewing out. Kill Bill style.
Having said that, Poland uses a lot of traditional medicine.
So if that works or not, I'm not sure. It's quite creepy. They say, let out the toxins, which is why you
I don't know even if there are studies with that coming up. So how many people must be how many people must be bleed out to see if there's a therapy which can change cupping up, belief studies were pretty much minimal where they went
With that they use it but they have found that it works.
It should be yes
At least it's supporting their work with cupping. I do know that most of the studies that they've done pretty much results, in poor results in pretty much any way shape or form
but they always conclude where it's non-invasive. And it's relatively cheap, non-dangerous.
Yeah. And majority of the time like Cera was saying, it relaxes her so a lot of the time even though you're gonna say even if it doesn't work on the actual it works when it works. It's a placebo effect person is going in there with the idea of alright I like this. It works and it will work for them if they think it will work for them.
It does have a placebo, it will have a placebo effect.
For us, we can go and touch the muscle after, muscles rock out did nothing for you but the person's like hey. Or it just it works with that person. It's something that they like going to its base feel that it helps. So for them it will actually work.
Okay, how about ultrasound?
I've seen positive results with ultrasound
For healing purposes again.
But because the shoulder joint is a fairly bony area, I have also seen people get burned. So when it's done poorly and spends too much time near the bone. I have heard too many places that have had come back and going: mate that was excruciating. What will happen like they were working to show it up. Here I'll see how much time did they spend like on a bone, that to me that�s why it is excruciating.
and Cera yourself what's your experience with ultra-sound?
I was at uni. That modaality of treatment I had it done before all this practice, I think, like compared to what Jackie said maybe for the bigger muscle groups may or may not have a benefit because it does. It�s most specific right and goes to the deeper layers but with the shoulder.
It's risky. Yeah.
I find that with ultrasound therapeutically, I don't like it too much, mostly because it's number one for the therapist who doesn't go and further their studies. They will refer to it over and over and it doesn't matter what they come into. You're going to have ultrasonic done. That's something I really dislike. Yeah, so it doesn't matter if you have got a massive tear or or little tear or just trigger points or just, you know, muscle cramping. You are going to be put placed on an ultrasound machine and I really dislike that. But however, if it's an area that is it's difficult and narrow and there's a tear that was trying to heal that I find that will work a bit better. Otherwise then we will have a lot of trouble with the recovery, that�s what I find. Dry needling, I think it's quite useful. So we do that often.
For me personally, I don't like to use it very often. But I think the benefits of that outweighs my reticence for using it
I primarily like using it when I see the muscles under extreme pressure. That's probably my first go to for the sole reason of it. The easiest way to decompress the area so it really relieves it, pretty much relief the area a fair bit allows the fascia and muscle to slide quickly, that's the only reason I usually do it. First up, if I see a very pressurized area, if I see it is very minimal, I'll probably avoid it as well. I, it's not my first go to, unless I see something very much under pressure where I've gone. Alright, let's get your results as soon as possible.
in one here, then other. Unfortunately, yes, if an area is under extreme pressure, then yes, the side effects are usually fairly extensive of where the area that feels achy. And that's the downfall of dry needling when it comes to this kind of thing.
About dry needling?
Oh, any other modalities that you do?
Or like to do?
No, it's just you mentioned once, okay, yeah, well, I'm a physio so we like to hammer the muscles
secret instead of using the blade the nano mohawk instead of just scraping it yeah I can see your Cera just whacking a patient with it.
So that we can see what you're doing.
So yes, so that's some of the why some things work why some things don't work
why we do
why we do what we do. ART
Well ART I like ART a lot because
What is ART?
ART is active release techniques it's been around in the North America for about 37 years now maybe because it started probably in 1980 1981. It is very well used in Europe and America, less so here in Australia. And even in Australia, it's not very well utilized, largely because it's a very difficult and in-depth and broad syllabus, so and the knowledge that we need to have with that it's quite mountainous I think. So what it is, is the, what people think of had their first impression is that, oh, you pinch and tack and stretch, but I don't think that's what it is as well. The best person who can actually explain to you now because she is fresh is Cera. So it's not tack and stretch anymore, isn't it Cera?
What do you think of it? Initial tack and stretch?
I guess umm Dr Kelly Starrett. Physical Therapist from America. He came up with this thing called mobility WOD so you typically use like a lacrosse ball or something to tack and pull a muscle and then move it through ranges, which is a stretch portion. So if you think about ART usually the therapist has a hold on a point of your muscle and get you to actively stretch or move through the range.
Not necessarily stretching.
Not necessarily stretching sometimes Yes, but usually it's more about getting the area that we are holding or to glide move, so that your muscle can actually move the way it's supposed to. Yeah, so muscles don't necessarily glide. They don't necessarily glide. The way that people are thinking about it. A lot of times the way the muscle moves and they will move in opposition or in or not, or simply synergistically, but what it is and also you can't really remove adhesions as a result of that, you know, you really can't what you're trying to do is to allow the fascia to not hold so tightly in place. So that the proprioceptive I'm going to go so you know, scientifically. So that's basically the fascia releases and then we can we are able to create a change as a result of that. So a lot of times people will, you know, the whole thing about our summary a bit about two or three years ago. It's all about the fascia.
And the doctor might be he was like, why did you think I was working on and he was so annoyed about it. And as a result of that, we can get range we can get into the little finicky muscles in the neck, a little finicky tendons and ligaments that is an elegant structural development of the human body to be able to move better. Essentially, that's what it is. So when people ask us what does ART do? It's like well, there's a lot of things that we it's like a whole afternoon that we can talk to you about it, right? So when you ask us a question, you know, do you want a lecture? And my colleagues really don't like asking me questions, because I'll sit down and talk to them for like for at least 48 hours non stop.
By the way, it's this and that and a whole life of like of being cynical. I'm going to walk away from you now Shermain. Yeah, so that's ART.
it's also one of the main treatment techniques what Jurmaine Health is known for. We do need to say that several times pretty much okay. Well, it's true. JH is known for Active Release Techniques in Victoria. And in Tasmania, believe it or not.
Yes it is
because there's only one other person that apparently practices in Tasmania actually doing it. So people come from Tasmania to us.
Oh Wow Yaay!
So we covered 2 stages. Awesome.
Well done. So what are we going to talk about the next time in Part 3?
Alright guys so next time we're finishing off our shoulder series and we'll be discussing sport and or fitness related shoulder pain.
So if you like what we're presenting, please give us a thumbs up a like or share it with one other person who you think we may be a help. For those of you who are coaches, dancers or athletes, and may find difficulty with expressing or executing movement patterns. Please do connect with us on our website, www.jurmainehealth.com.au and Jurmaine Health is spelled j u r m a i n e h e a l t h. Or please socialize with us on Facebook, which is Jurmaine Health or Instagram which is Jurmaine Health body. And last but not least, since this podcast is made for you, our clients, patients and fans, please do let us know what else you might like to hear about. And that's us signing out for today. Bye.
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