Shoulder Pain Seminar On-Demand

Shoulder Pain Seminar On-Demand

Articles Blog


(bouncy music) – Basically you have the
musculature of the shoulder, the supraspinatus, infraspinatus, and subscapularis, teres minor, these make up the rotator cuff. And it’s surrounded by the
acromion, which is a bony shelf, and the ball is underneath the muscles. Next slide. What are some of the symptoms that you may have of a rotator cuff tear? This is also true for
impingement syndromes, which I’ll talk about in a little bit. Pain at rest, pain at night, particularly when you’re sleeping on
the affected shoulder. The pain is mainly over
the apex of the shoulder. Rarely will it radiate past the elbow. If it’s going past the elbow,
it’s usually neck related. Pain when lifting your arm up. It’s usually from about 35
degrees, up to about this level. You notice lifting pain. It doesn’t have to be
very heavy, it’s just when you get your arm in a
certain position it’s painful. You may notice some,
what we call crepitus, which is some grinding
or crackling or rubbing, kinda like leather rubbing over leather, when you move your shoulder. You may also notice some limitations of motion in your shoulder. Now for women, I ask them can
they undo their bra in back? They can’t reach back any more. For men, they can’t get into their wallet and that’s when they come in. This didn’t show up that well, but this is an arthroscopic view
of a rotator cuff tear. This should be coming down and attaching right here to the bone. Why do we get rotator cuff tears? Well, the rotator cuff doesn’t
have a good blood supply. This is all white tissue
here that you see. That means there’s not good
blood going through it. And if there’s not a lot
of blood going through it, it doesn’t heal well and it will tear. Repetitive stress. Usually we see this after
the first snow storm. Everybody’s out shoveling snow and then a few weeks later
they come and they say, “You know, I hurt my
shoulder shoveling snow. “I don’t remember doing
any one specific thing, “but I can’t lift my arm now.” They can have bone spurs
off their acromion, that I’ll show you later. And this can cause an impingement syndrome where, if you have a bone spur here and you just imagine lifting
your arm out to the side, you’re hitting that spur. So we flatten it out and
give you more room to go. And this is a diagram of
an impingement syndrome with the arm down. You can see there’s plenty of room between the rotator cuff and this acromion bone. When you lift the arm out to the side, the rotator cuff gets
pinched between these two, and that gives you a tendonitis, bursitis, partial tears, or full
tears if it’s allowed to continue for enough time. Shoulder impingement is an
early stage of a cuff tear and if you allow it to continue
you can end up with a tear. So we try to be more aggressive in treating the impingement so that you don’t progress to a cuff tear. Next please. Rotator cuff tear can occur after a fall. Here you see the tendon
should attach to the bone. And the mechanism of this
is that the rotator cuff pulls your arm out to the side. That’s simplifying it. It actually pushes your arm down, but it helps pull your
arm out to the side. If you fall on your arm, it’s gonna push your arm down and separate it. The rotator cuff is trying
to keep it out here so it braces the fall and
it doesn’t hurt as much. And when your arm gets forced down, the tendon gives and you get a tear. And that would be a horizontal tear. Next. These can also occur
over a period of time. Months to years. It’s from repeated micro trauma or repeated inflammation in the shoulder from a chronic tendonitis or bursitis. Again, it’s because of a poor
blood supply and impingement. If I get in your way, just tell me. Next one, please. This shows a partial thickness tear. And if you were to look at a rotator cuff in a cross section, it’s a thick tendon, and you can get a partial
tear where a few fibers tear, or a more significant tear
where half of it tears, to where there’s only a few fibers left, to a complete tear. And treatment depends on
what kind of tear you have. This is what a full thickness tear is. Here’s a hole in the tendon and you can look right through and see the bone. Next please. And this is just an arthroscopic view of a rotator cuff tear. This is the rotator cuff coming over top and it’s lifted off the bone. This should be, this should be attached down here. And I’ll show you some other pictures of that and how we repair it. Everybody wants to get
an MRI of their shoulder to see if they’ve got a tear. This is what an MRI of a tear looks like. This is the ball, the socket, and this is the rotator
cuff coming across, and it should attach to right here and here you see a defect. And the best way mechanically to think of a rotator cuff tear and what it does is if you’ve got a car, you’ve got
a motor which is the muscle, you’ve got a wheel that turns, but the rotator cuff is a transmission so there’s no power getting to the arm and that’s why they can’t lift
their arm out to the side. Partial tears we treat by rest. Activity modification,
we try to avoid anything above shoulder level, keep
all your work down in here. Strengthening exercises
in physical therapy. And Gary will talk about that. The rotator cuff actually
keeps your shoulder down when you lift it out to the side, that’s the main function of it. So we strengthen those muscles. Steroid injections. Now you get a steroid injection, I tell patients to take the pain away so you can do your physical therapy. The physical therapy is what’s
going to cure this problem. Not the pain medicine. The injection is not a license to go out and play some tennis, shovel snow, and do all this other stuff. It’s to decrease the pain so you can sleep and you can heal the arm. If there’s a larger tear requiring, more than 50% it usually requires surgery because it’s not going to heal. And that’s because of
the poor blood supply. When do we talk about surgery? If you’ve had symptoms for six to 12 months with a small tear. A large tear more than three centimeters, we know it’s not going to heal, so that’s gonna need surgery. If there’s significant
weakness and loss of function of the shoulder where you can’t lift it up more than that level. Or if it’s an acute tear that
was caused by a recent injury. You know you fell on your
arm, you can’t lift it, we know they’re gonna do far better if they’re repaired acutely. Leaving these go a long period of time, the tendon retracts, the muscle fibroses, and it’s much more
difficult to get the tear back to where it belongs and
it does not heal as well. And some of them actually
cannot be repaired. So there’s several different ways to perform a rotator cuff repair. There’s the arthroscopic technique. A mini open technique, where we just use a real small incision. Or the old, (coughs)
excuse me, open repair, where there’s a large incision. And if there’s a very,
very large tear that can’t be repaired, we do what’s called a reverse total shoulder replacement. Special kind of shoulder developed for massive rotator cuff tears and arthritis that cannot be repaired. This is what a schematic
of a rotator cuff repair. This is the rotator cuff. There’s a little, like
molly bolt with sutures coming out of it, and we use that to tie the rotator cuff back down to the bone. And I’ll show you a recent
surgery that I did with that. Open cuff repair is kind of gruesome. This is the head up
here, that’s the armpit, and the collar bone, and it’s a pretty big incision in the arm. Next. Later on, there’s a mini open cuff repair. It’s a real small incision, maybe an inch, just enough to get some
instruments in there, get some sutures in the
rotator cuff and tack it down. Nowadays we almost all use suture anchors, because this bone, this tissue’s avascular and you’re reattaching it to bone, and you can’t put sutures into bone. They’re not going to heal. It’s like trying to put it into wood. So we use like a molly bolt
type of affair to do it. Arthroscopic repairs are small incisions. We have to use special
instruments to do it. A special shaver, special tacks, special suture passers, a video camera. And the healing is much faster, because we’re not making
these big incisions. Next. This is what a normal
rotator cuff looks like through the arthroscope. That’s the bone and the rotator cuff is coming down and attaching. This is what a tear
looks arthroscopically. Here you can see that the
tissue now pulled off the bone. It doesn’t show as well
here, but this is a white tissue when you look at it live, you’ll see that it’s white. There’s very little
blood supply going there. And again, this is what it would look like with sutures coming to
tack it down to the bone. Next. Another dichromatic of
a tear being repaired. Next. And that’s what the
completed repair looks like. Next. Can we turn down the lights just a little bit so this shows better? This is a video of an arthroscopic repair. Here I am probing the hole. That probe is going into the
hole in the rotator cuff. And notice how you don’t
see any bleeding here. It’s all avascular tissue. Okay, this is a probe coming in. And I’m just trying to see how big the tear is and how mobile it is. You’re gonna see a special
instrument come in, this is a suture passer
and this is like a clamp. I’m gonna grab the tissue, open the jaws, and you’re gonna see the sutures come out. That’s deploying the suture. And now that’s suture in the rotator cuff and coming through. We’re gonna feed the suture through. And now there’s a good braided suture. That’s about a millimeter and a half thick in the tendon. Now we’re gonna come down here and I’m gonna make a hole to put the the screw in. Here we come. This is the instrument
coming in to make a hole. Now we actually have to tap the bone. You’ll see the screw’s coming in. The threads coming in. I’m tapping that part in. But you see, these are threads. These are cutting the threads
for the suture anchor. It’s a tap. Next I’m gonna pass the suturer, the actual anchor in
there, the molly bolt in. That’s a white bioabsorbable material. And that’s got the sutures held in it. I’m going to screw it into place. And then start ratcheting it down and tightening the sutures. Now see the sutures come down. You see them coming into the anchor. And that’s pulling the torn
portion, that hole, closed. The anchor instrument comes out. And we’re gonna cut it. Now just for perspective, that molly bolt, that suture that I put in there, is 5.5 millimeters thick, so there’s a lot of magnification
with the TV camera. And that’s just cutting
(clears throat) the suture. And that’s the completed repair. Okay, next. If we can’t repair it and you develop an arthritis in the shoulder, we do what’s called a
reverse shoulder replacement. And in this case the ball
is at the end of the socket and the socket is where
the ball normally is. The reason that we do this
is in a normal shoulder if this big muscle contracts, it would pull the shoulder up. But what the rotator cuff does
is push the shoulder down. If you don’t have any
rotator cuff in here, when this muscle contracts
to pull your arm up, this is more horizontal and holds it down. But there’s not a big indication for this. It’s only for more severe
tears, elderly patients, and secondary arthritis in the shoulder. Next slide. This is a conventional total shoulder where the ball is just cut off. A stem and a artificial ball is placed, and sometimes we’ll replace the socket, depending on how bad the arthritis is. This is used for osteoarthritis, or arthritis of wear and tear, rheumatoid arthritis, post-traumatic or after fractures sometimes we have to do this when the ball can’t be repaired. If you have a combination of
a severe rotator cuff tear that’s not repairable and arthritis we do a shoulder replacement. People who are on steroids for asthma, pulmonary GI complaints,
can develop a condition called avascular necrosis
where the bone actually dies. And that leads to a severe
arthritis in the shoulder. And we can also do it for
failed previous surgery. Next. About 23,000 shoulder
replacements are done a year. And this compares to about 700,000 hip and knee replacements done a year. So it’s not as common of procedure, but it’s still a fair
number that are done yearly. Next. When you’re talking about
arthritis in the shoulder you’re talking about boney pathology versus the rotator cuff,
which is soft tissue. And what you see in
x-ray findings are loss of this space between
the head of the humerus where the ball and the glenoid
or the cup of the shoulder. You can see flattening of the head. You can see bone spurs in
here or under the ball, or loose pieces of bone
floating within the joint, and those would all be signs
of arthritis in the shoulder. This just shows the difference
in the two shoulders, two types of shoulders. This is a traditional shoulder replacement and this is a reverse shoulder, here you can see the ball’s attached to the end of the humerus and the socket is in the socket of the glenoid. Here you see the ball on
the end of the glenoid and the socket here. But if you can just imagine
this muscle pulling up over here it would just
pull the arm right up. There’s nothing to hold the ball down. Versus this is underneath
that ball and that keeps it in place and allows the
arm to rotate laterally. Next. Symptoms of arthritis
are pain, loss of motion, that grinding sensation,
lack of sleep, stiffness. You’ve all heard of these. Next. What are the non-operative treatments for shoulder arthritis? Well, number one you got to rest it. Moist heat can ease the pain. If you’ve been exercising
it a lot ice helps, particularly at night. Physical therapy is a
mainstay of arthritis. In our group we’re very
aggressive in physical therapy. Non-steroidal medication used to be the mainstay of treatment. I don’t know if you remember Vioxx was a great arthritis drug. It was taken off the market because they found that there was a much higher incidence of heart
attacks and heart events after Vioxx, so they
took it off the market. Well then they went back and
looked at all the old drugs, the Motrin, Advil, and all those, and found that they all
have the same effects, but to a lesser degree. So when you’re taking
over the counter Advil you’re still increasing your
chance of a heart attack, GI bleed, and kidney disease,
and liver with some of them. So we’re much more careful in recommending the non-steroidal medications
than we used to be. Periodic cortisone injections
can help with the pain. The problem with cortisone
injections is that they interfere with cartilage metabolism and over a period of time they can make your arthritis worse. Next. Again, this is the conventional
shoulder replacement. It’s a metal ball with a socket. It’s patients who, at the end of, if you were to open up
a joint and look inside, you’d see the ball like
in a chicken joint, it’s covered with a nice,
white, pearly substance that’s slippery and in arthritis that white, pearly substance has worn away and there’s just bone there and you see bone rubbing against bone. Usually we replace the
ball and the socket. If the socket doesn’t look too bad, sometimes we’ll just replace the ball. Next. This reverse shoulder is rather new. It was first approved in 2004, so it’s a relatively new procedure. It’s only used when there’s a
completely torn rotator cuff. And the secondary arthritis
that you get from it. It is not the gold standard by far, but it’s the salvage
procedure when a standard shoulder replacement won’t work. But it is a good procedure and we like to save this for our patients
in the 70s and 80s rather than the younger patients. Next please. Post operatively for all
shoulder replacements, you’re in a sling for three to six weeks until you have control of
your shoulder on your own. You’ll be doing exercises
in therapy day one. No driving for about six weeks and you start light lifting at about two weeks. And I’ll entertain all
questions after Gary and. (Applause) (bouncy music) – We love to talk about physical therapy. For second, at least, in
my wildest imagination, over the years, I always imagined some day being able to, in a seminar, with my son. That’s kind of a special moment for me and I’m truly glad I
get a chance to do it. Dr. Busch, always enjoy hearing Dr. Busch. We learned a lot of things. I’m gonna try to focus on a couple things. So you can take something with you, that when you think back on tonight, you can say, “Well my shoulder hurts. “Oh yeah, that’s right.” So I’m not gonna try to give you a lot, but I’m gonna give you a different look at the way you probably
thought of physical therapy or exercises for these kind
of shoulders in the past. I brought along with me tonight, Linda, where she’s at? One of my past patients. I’m gonna bring Linda
forward, I’m gonna ask her a couple questions, and then I’m going to go take what Linda talked about and put it into something
you can hold and remember. Alright. Linda had a rotator cuff. Now, Linda, what did you do for work then? – I was a health and
physical education teacher for 30-some years and I
played competitive volleyball for 43 years, so I used my arms a lot. – So here I have a volleyball player who has torn her rotator cuff. You know what her desire is. What did you want to do? What were your goals in physical therapy? – To play volleyball again. – So the first thing she
comes at me and says, “When do I play volleyball?” We’re in a sling, you heard him say three to six weeks on those slings. First question, “When
can I play volleyball.” Now that could come
back at you as a shock, but you know what? That comes to me as a blessing. Because I now have a
physical education major, who wants to get back
to playing volleyball, who has to learn how to exercise
just the way I tell her. My odds are good, because of her understanding of exercise. So you had the surgery done, tell me about you had some responsibility in your rehab. What did you have to do at home? – I had a home program,
I would go to therapy two to three times a week
where he would take care of me. (laughs) And then he’d give me a program that I was supposed to
sustain for the days that I wasn’t in therapy with him. And it was really important
that I do what I was told to do, so that I could progress and
get back to playing volleyball. – And how did you progress? – Very well. Very well. I looked back and about a week later I was back at work. And about seven weeks later I was doing most everything and the first time I had an impingement on my
right shoulder and then years later I had an
impingement on my left shoulder, 10 years later I had the
rotator cuff surgery done. And I got back to playing volleyball in eight weeks and 12 weeks. That rotator cuff was a
little longer than that. – She talked about what she had to do. If I had to tell my students, when I get physical therapy students coming through, I tell them this is the
thing you learn about being a physical therapist. Number one, what you do is 10%
of the success they’ll have. What they do is 90% of the
success you’ll both have. So we establish some goals. We establish the fact that
exercise was important. And then we gave her things to do. Her success rate was good. Did you keep doing your exercises after you were out of physical therapy? I didn’t want to embarrass
her, but you know what? When I give exercises for home programs my first thought is,
“You have to understand “why I need you to do this.” And that’s what I’m
gonna talk about tonight. Thanks, Linda, so much. Yes. (clears throat) Okay. I’m gonna make a little
bit of a drawing here. To explain what I’m trying to
do and so everybody can see. Can you guys see? Let’s turn it a little bit. Then you guys can see? Good. This is my favorite thing to do with my patients when they come in. Some time ago when I was, I gave a lecture some time ago, and this kinda just fell into the lecture and I’ve used it ever since. I’m gonna make a little
drawing here in a circle. It’s gonna represent pain. There’s some causes for pain and we’re gonna talk about them. Now if I say pain is the good guy, everybody that believes and
buys into that, raise your hand. You must have been in
physical therapy before. Because pain is nothing
more than a messenger. He’s a messenger. Dr. Busch had it right on the target. You can take those
injections, those steroids. You can take the medicines you want. You can use ice cold
and everything you want, but you’re shooting the messenger. That would be like if I took my son Jared and said, “Go out in this drug cartel, “get me all the information,
all the names of the people, “and when he came back I shot Jared.” Wouldn’t make any sense
to shoot the messenger. So why do we do these things? Why do we do these medicines injection? Because sometimes we’ve
got to control this guy so we can do the things we need to go. We need to put ice on so we can control the things we need to do. We’re gonna inject so we can do the things we need to do so we can
take away the cause. This is a shot at the symptom, pain. Causes, we’re gonna talk about. Two categories, cause. We’re gonna talk about pathological causes and physiological causes. Big words. One means bad and one means, not so bad. The pathological ones,
when you see your doctor, these are the ones they
do the studies for. And he showed you some bad
stuff on that presentation. Those arthritic shoulders, that torn cuff. Just recently, I had a
patient come back last week. He went out to, his
shoulder’s killing him. Can’t sleep, up at night, can’t work. Wants to throw up when
he comes to therapy. He went to get his MRI done and his x-ray, ’cause that’s all he wanted. In the internet, and
on the, it says on the normal treatment I should have an MRI. So he got an MRI done. It was negative. That means they didn’t
find a tumor or a cyst, a tear, a fracture, a labrum. The didn’t find any of the bad things. They didn’t find a fracture. He was sad that they
didn’t find that stuff. You know why he was sad? Because he said, “Now no one knows why I have pain.” That’s not true. This side of the formula, pathological, has some bad stuff. We
saw some on that video. And because it’s bad, it can have an influence on this side as well. Now we’re gonna talk about this side. Has anybody ever had their arm in a cast? Come on, somebody had to. There you go. How long were you in the cast? – [Man] Uh, couple months. – Okay, when it came out, was it stiff? And was it sore? – [Man] More stiff than sore. – Okay, so you had this
stiff, sore shoulder. Here’s his arm, in a cast. Nice cast. There’s his shoulder, here’s his elbow. Let’s put this part in
with nothing wrong with it and when it comes out,
nothing wrong with it. It’s stiff and some soreness. That’s just with loss of
range of motion and strength. So when we talk about
this physiological part, it has two players. Player number one, player number two, range of motion, strength. Losing range of motion
and strength in a cast makes a joint sore that wasn’t even bad. So consequently, when we feel pain, some of the messenger that
we get comes from this side. Yes, we may have something
over here that’s minor, or even major that requires
us to be in immobilization, that does lose these. But without a doubt, loss of motion, range of motion and
strength, will in itself be a pain generator. And the reason for it, when we lose range of motion or strength, that word’s mechanics, we
change the way they use it. If my shoulder hurts when
I pinch at picking up, I start picking it up like this. I start lifting it ip like this. I start doing this to go behind my back. All those substitutions
are mechanical changes. Because I’m not using it
the way it was designed, I can start getting problems
above, below, or at. So let’s so it’s your shoulder, but you have this bad neck ache that just won’t quit. You’ve got this elbow that’s
sore on the inside and the top because every time you to
reach in it won’t go there and you reach in with your
forearm and it gets sore. So now you’re scattering your pain below, above, and at and the reason for that is, everybody’s familiar with the -itises, tendonitis, bursitis,
capsulitis, arthritis, myosistis, all the -itises. Those -itises are caused
by doing it the wrong way. Having another part doing
what it wasn’t designed, you cannot expect it to feel normal. I tell my patients this, abnormal can never feel normal. I mean, you can’t fault me for that, you gotta talk to the grand maker. If something’s being used
wrong, it’s gonna feel wrong. Something’s used right, has
a chance of feeling right. But abnormal can never feel normal. And the messenger to tell
you you’re doing it wrong, is pain. So with this in mind,
alright, I’m gonna now jump over here, I think
I’ll leave that though, and bring my son up, my other son’s here. This is why I had sons. (audience laughing) This is my son, for that reason he really believes in
flexibility and he has none. I’ve told him, I told this one too, I told them all, you
have to stay flexible. It’s why I, at 64, can still
do some of the things I do. So consequently, we’re gonna show him some of the reasons and some
of the ways people cheat. Now he’s gonna first put his
arms straight out to the side. Now it looks the same probably
to you, on both sides. But if you look at his shoulder, this is your sore one, isn’t it? Yeah. You see how this shirt just
folds in like it’s supposed to? That’s because this wraps around. Remember what Dr. Busch says? The ball ducks underneath
there, takes that shirt down. This one looks flat because,
remember when I showed you how they cheat? That’s a cheat. Put it down there. Put your hands behind your
head, like you surrender. In this position, what you should see is, this is (mumbles) rotation, two triangles. These two triangles should be roughly the same on both sides. Let me look. This looks like somebody squashed
his triangle, doesn’t it? That’s because this
shoulder, taking his shirt, sticking up, ’cause he’s cheating. Alright? Let it down. Hands behind your back. I’m
really sorry I’m doing this. Go ahead, hands behind your back. – Where at, low? – Right like that, yeah. In that position, you can’t
see it so I’ll turn him around, if I take my hands and go across his back, I run into his wing bones. They shouldn’t be sticking out like that. If I put my hands behind
my back, it’s flush. He can’t do it because he
does this to make that motion. He is in a backup system. Turn around and let your hands down. It’s like having a limp in your shoulder. You ever see the person that
sprained their ankle then limps and then months later still walks with their foot turned out to the side? That’s a habit limp. The human body’s made
up of all kinds systems and backup systems. We automatically slip into those systems so we can keep going, even
though it’s not the right way. Thank goodness for it. We use it actually, many times with people with broken necks, quadriplegics, we can get them to use
their arms in a way, what’s left, wrong, but
they can get around. Will it last? No. Will not last, the wrong
way, so consequently, thanks. There’s a right way of doing it. Now, remember, all those pictures you saw. This is one of your rotator cuffs. Here’s another guy, this goes underneath. And these guys are on the
back, come in through here. He talked about the fact that
it spins the ball around. Now, this bone on the top, roof bone. Touch your roof bone. Everybody knows where it’s at? Got it. Collar bone, squiggly guy in the front. Arm bone, ones you’re moving. Wing bone, that guy in the back, that his was sticking out sideways. What was happening? There’s a ligament in here, on Jed, and on every one of us, and ligaments keep joints from falling apart. They’re number one. Don’t have ligaments? You dislocate. Tear a ligament? You dislocate. It holds the joint, the balls,
together, the two bones. The next guy are the rotator cuffs. They’re the steering guys. As he talked, Dr. Busch talked, they steer the ball down underneath. Because right here, you saw him repair it. Is the only tendon in the body
that sits between two bones. Now you may argue with
the way it was designed, but that design gives us the ability to do something that other species can’t. It gives us that ability to
have motion in our shoulder in a myriad of directions. This roof and this ball
would pinch together and catch that guy if he
can’t steer it through there. Well what could stop it
from steering through? Remember we talked about
range of motion loss? If this ligament gets tight,
how would it get tight? Remember we said you’re in
a cast, things get stiff. How many times have you had your hand up above your head higher than you look? Most of the time you’re out here and if you look at that, it’s a lean back, and it really isn’t up in the air at all. We start losing things
when we don’t use it. You don’t use it, you lose it. Suddenly, we start giving up motion. Well what’s so important about that? When I pick my arm up, right now take your hand, put it in your armpit and you’ll feel a ball bulge in there. Unless you’ve got a bad shoulder, then it won’t bulge in there. That bulge is your
humerus coming in there. If it’s too tight, watch what happens. Everybody’s waving, that’s like. If it’s too tight and the arm comes up, the ball goes here, stops,
slams up, pinches the tendon. The very tendon that’s
supposed to be spinning and steering the ball. So one of the things we need to do is make sure we’ve got that range of motion. And that’s what we’ll look at first. Then we’ll look at the guys that steer. If they’re getting pinched enough. Boy scouts, you have a rope. You forgot your knife,
you have to cut the rope. You take round rocks,
you bang them together, and soon what happens? The rope frays and tears.
Degenerative rotator cuff tear. You bang it enough between two surfaces, expect it to wear out, flatten. You know how you tenderize
chicken and it gets skinny? Imagine doing that to your tendon. Getting it skinnier and
thinner, has a name actually, and then finally, you
do something, it tears, you say, “All I did was this.” Yes, but you’ve been smashing
it who knows how long. So it’s important to know
this range, this guy’s strong, and then, and Jar’s gonna talk about this, worry about the other guys on the outside. (audience applause) (bouncy music) – I volunteered, got volunteered, to give a little talk here. They said maybe talk about
rehab for shoulder pain and I said, you know,
you could write 10 books about that and still not be done. So I thought, you know in
10 minutes, or whatever. So I said, what are probably the most common questions that we get? I work downstairs. What are the most common questions that we get in this office? I thought about the questions
that maybe I could help, maybe say something
that would help somebody and probably the most
common question we get is, how long have you been here and why’s it so hard to find this office? (audience laughing) The first part of that is,
we’ve been here like two years. And I guess the second part
is something to do with signs, there’s no signs or something. But you know, the next thing people usually ask me with
exercise is “Why am I here?” And I guess meaning the
nonphilosophical way of why am I in physical therapy. And I say, probably because
the doctor sent you. And then they say, “Well,
what can you do for me?” And I said, well, like my dad was saying, like Dr. Busch was saying, you know there’s mechanical things
that you have to change in your shoulder or it’s
not gonna get any better. And then you could do so many
different kinds of exercises and it can get overwhelming. People say, they always
come to me and say, you know I wanted to
get my shoulder better so I went to the gym and
I started lifting weights and it hurts more. My one friend that used
to go to the gym with me, he came to therapy and he said,
well I was lifting weights and the one guy at the
gym, the guy at the gym, the guy you don’t want
to listen to at the gym, he said well if it hurts while
you’re doing bench press, just keep putting more weight on till it doesn’t hurt any more. And it’s like,
(audience laughing) it’s like the say, one of
the definitions of insanity is doing the same thing over and over and expecting a different result. So, I started thinking, stuff
can get really complicated, especially these days. We take simple things and
make them very complicated. You know life has become very complicated. I always think, if stuff gets complicated, you got to simplify it. So I always try to find models, analogies, ways to think of things. And so I kinda made a little model that’s similar to, you know, everyone
knows the food pyramid. When I explain to patients,
I’ll say, you know think of what the food pyramid is. You know, why they have it like that. They got, I don’t know much about food, but I know they got grains somewhere and vegetables and all that. Then, whatever’s on the bottom,
you want to do the most. Whatever’s on the top, you do,
you know, that’s the least. So what I try to do when
I’m talking to people and I’m saying, oh, you know, you can do this exercise or that exercise, and they’re like, well,
I’m can’t come to therapy. Or, I’m gonna have surgery, what am I gonna do after surgery? I say, let’s simplify it. Let’s just make a model for you to use. So I usually just sometimes
I draw it, sometimes I just tell people, but
for this we’ll do… So, like my dad was saying, there’s different things that you need to work on when you lose this
mechanics in your shoulder, you need to start somewhere. So, I’ll use like a baseball player. Everybody knows what a
baseball player looks like when he’s throwing a ball. So the first thing, if you
want to throw a baseball, or if you wanna, you
know, hit a golf ball, or if you wanna work in your yard. Or some people it’s just as simple as walking up and down the steps. The first thing you’re gonna
need is range of motion. So I put this on the bottom. If you don’t have range of motion, if you can’t move your
arms, you’re not gonna be able to do anything. If you can’t move your
arm in the right position, you’re not gonna be able to throw a ball. So you have to get your range of motion. Like my dad said, if you don’t get the range of motion correctly,
you’ll end up compensating, you’ll hurt other joints, you can end up tearing your rotator cuff
off, you can pull muscles, all of those things can happen
because of range of motion. There’s all different
kinds of range of motion. There’s just lifting your arm up and down, there’s having someone
else move your arm around, there’s stretching, and
that’s the kind of stuff you would need a therapist or a doctor to kind of show you what specific range of motion exercises that you need. But after you get your range of motion, a baseball player, he can move
his arm in all the positions. After that, what you want
to work on is gonna be, it’s gonna be your strength. If you get your motion first, then you start working on the strength. I have a, part of our family
and friends and stuff, are personal trainers and they used to call me on the phone and say what should I do for this guy, what
should I do for this guy? I’d say, if I was a personal trainer and someone came to me, the
first two or three weeks all we would do is stretch. We’d make sure they had all
the motion of all their joints. Then after that we start doing
some strengthening exercises, especially for the muscles that
a lot of people don’t work. We all know the muscles
here, but there’s hundreds of muscles in your bodies
that many people don’t use. Hundreds of years ago,
the Indians, everyone, they were climbing trees,
running across the plains, they’re using all their
muscles all the time. We don’t use them like that anymore, so we lose range of
motion, we lose strength. Once you get these two things back, then you want to work
on what I would call, like your form, your technique, your posture, your core exercises. If you watch a baseball player,
if I stretch your arm out and then we did some
strengthening exercise, and I said okay, now you can
go pitch for the Phillies. It’s not gonna happen. You have to get, you have to get someone that’s gonna show you how
to throw the ball correctly. You have to have someone showing
you how to lift correctly. You have to have someone show
you how to hit a tennis ball. Anyone who plays golf
knows that just because you stretch and strengthen
doesn’t mean you can hit the ball 300 yards down the middle. You need someone to teach you
how to do it the right way. And then, after you have all
of three of these things, then what you’re gonna
do is your exercise. So a lot of people will say to me, you know I wanted to get in shape, so I’ve started playing racquetball. And I said, well did you stretch
for a couple weeks first? No. Did you do any strengthening
exercise for your rotator cuff? No. Did you take any lessons or have someone show you how to hit
the ball correctly? No. Well you skipped these three steps, went to the top step, and you got hurt. So I think a lot of
people get hurt that way. It could be as simple as jogging, hiking, like I said, stairs,
golf, anything like that. If you’re gonna do
anything kinda exercise, you want to start from
the beginning and work all the way to the end. And that’s the same way
we do it with surgery. After someone comes in
with a shoulder replacement or a rotator cuff repair,
after we have surgery, we start just with range of motion. If someone gets all the range of motion back in the right time period, then we start doing a
little bit of strengthening. Then after we do the strengthening,
like my dad was saying, we watch how they’re lifting their arm, we make sure you’re not compensating, we make sure if you’re
going back to baseball we have kids who play
baseball, hockey, soccer. Are you throwing the ball the right way? Are you hitting the ball the right way? And then after you’ve
done all those things, then you can go back to your sport. And then, you know like my dad said, you’ve got to keep with it, you’ve got to keep doing your exercise,
you’ve got to stick with it, and then progress it down the road. The other thing that people
usually ask me is say, “Okay, I got all these exercises. “So how do I know if it
hurts when I’m doing it, “should I stop? Should
I do something else?” I kinda made up a general rule, this is something you
gotta talk to your doctor, you’ve got to talk with your doctor about, you gotta go by your own
understanding of how your pain is, but my general thing
is, this is what I do. When I’m exercising, if I’m in a gym and I’m bench pressing and I
have some pain in my shoulder, what I’ll do is, I’ll say, if
it hurts while I’m doing it, maybe I’m gonna stop. And I’m gonna check that
my technique is correct. If my technique is correct and
it hurts while I’m doing it, I’m gonna have to stop that
exercise and back down here. Maybe start with my range of motion and go back to my
strength, make sure my form is right and then try it again. So when you have pain during
an exercise, you reevaluate it. Am I doing this correctly and
if you are and it still hurts, you have to stop and
move down on the scale. The next way I do it is if
it hurts immediately after, so say you’re out in the
garden and you’re doing stuff in the garden and you get
back in and all of the sudden you’ve got pain in your shoulder. And then you say, okay,
what I usually tell people is that you probably did a little too much that you weren’t ready for. Back off the intensity. So if, you know, despite what my friend’s, the advice he got at the gym, usually if you’re lifting too much and
it’s hurting your shoulder, you want to back it down a little bit. If you back off the
intensity, if you back off the weights you’re doing
and it doesn’t hurt, you probably can slowly work
back up to what you were doing. And then if, I always tell
people if you have pain you know, a day or two
after, it’s pretty normal. You know most people,
especially when they’re starting to do something new, they get a little sore in the muscles and once you do it for a while that
won’t be a problem any more. The other thing I would
say is if you get pain afterwards and it’s an intense pain and it persists long enough,
you know you definitely want to talk to a doctor about that. So. – Thanks. And one final thing is we, and then we’ll take some questions. I thought of it while I was talking and I didn’t know how to
get into it because I didn’t want to move into this in case I was to cover everything,
that’s my problem. Total shoulder replacements. Just like total knees,
just like total hips, just like total ankles, total anything. You’re putting something new inside, but if you haven’t prepared it, you still have an old, bad
structure on the outside. So if you’re thinking about
or you’re at that point, you’re talking to your doctor, take some time, find some
time, get what you can before your surgery. Like the athlete, he has it all. Get as much as you can,
because afterwards, if you put a new shoulder, new joint, in a bad, tight shoulder, working with us is not as much fun as it could be. If we have a little,
every little bit makes a difference on what we can do. So if you’re thinking about those things and you’re at that level in
your life and you’re wondering. Talk to your doctor, see
if you can’t get some beginning rehab, because you may find, and I just had a lady who’s doing so well with her knee that she’s gonna
wait on her knee replacement. The doc said that’s great. ‘Cause the better she gets,
when she does finally need one, the easier it will be in rehab. Alright, thanks everybody. Dr. Busch, want to come
over and get some questions? Ask him all the questions, that’s fine. (audience applauding) (bouncy music) Any questions? Yes. – Dr. Busch, in some of those examples, illustrations on the screen,
it showed the rotator cuff, but it seems to me there
was sheath that went around. Is that also part of the rotator cuff? – I believe you’re
talking about the kind of a red thing coming down? – [Man 1] Well I didn’t see
a red thing, it was white. It was a thin strip coming
around and I’m curious, the word sheath that that’s
the reason why I’m using it, is because, and this is a personal thing, apparently this sheath has degenerated. I don’t have anything between the bones. So what do you do there to repair that? Does that require partial
shoulder replacement? Or total shoulder replacement? – Depend how big, what you’re
talking about as a sheath, I think is the rotator cuff itself. – [Man 1] Well the doctor
did not mention rotator cuff. I don’t know the other word for it though. – Bursa.
– [Man 1] Could have been. Could have been bursa, but
it’s just bone on bone, that’s, simply that’s it. – Well, it depends how big the tear is. If it is a torn rotator
cuff, if it’s arthritis when you’re talking about bone on bone. – [Man 1] I think it’s more
arthritic, there was no tear. – Well, if the rotator cuff is intact, you’re bone on bone, then you could have a conventional shoulder replacement. – [Man 1] The next part
of this question is. – Just ball or the ball and the socket. – When you have that done,
I’ve also heard that, I’m an active person,
I ski and I play golf and do things like that,
that I may not be able to lift more than 25 pounds,
I may have a little problem being active in skiing, playing golf, that sort of thing when I
have a total replacement. – I think we try and limit, I would be a little bit uncomfortable
with you skiing. Not for the act of skiing,
but for the falling. You know, damaging it that way. – [Man 1] I’m fortunate. I don’t fall. – Golf is fine, you know, you should get your range of motion back. That shouldn’t be too difficult. You know, in the upper
extremities you’re not seeing the forces
generated across the joints that you do in the lower extremities, like with a hip or a knee. So I think golf would be… – Golf is good to have, tennis, I usually ask them to play doubles. So there’s a little less
hitting, little less reaching. Real high above the head
service is a little difficult. But there are ways to serve, side serve. By this time, when they come to me, they’re already have gone down to that side serve off the top. If you’re playing for the
recreation of it, it’ll be great. If you’re still trying
to make the Wimbledon, you’re gonna be sad. – [Man 1] Thank you. – Yes. – A question for you. It seems that in the diagnostic mode, a lot of the emphasis is put
on the MRI to say what’s wrong. Question really is in three parts. Is there any other diagnostic tool that you would use if you didn’t
have an MRI available? Two, how successful is
the MRI in predicting, in looking at it, how
often is it right in saying you’ve got a rotator cuff problem or not? And three, if you have an MRI that says everything looks fine,
but you’ve still got chronic and acute pain,
what do you do next? – Well, first of all, most orthopedists make the diagnosis on the basis of a history
and a physical exam. Talk to you, see what your pain is, how it started, how long you’ve
had it, where it hurts you. Do an exam to see what your strength is, your range of motion. And then we’re doing an MRI
to confirm what we suspect. This is what we do all day. So for us, the MRI is
mainly a confirmation. I may not be able to tell
whether you have a partial tear that’s 90% or a complete tear, but I could pretty well
tell you you have a tear. And I just need that MRI
to tell me how bad it is. – [Man 2] And if the MRI says
no, you don’t have a tear, but you still have the pain? – [Dr. Busch] You may not have a tear, you may have an impingement. – [Man 2] Okay, which is really what? What’s an impingement? – [Dr. Busch] Tendonitis,
bursitis in that shoulder. – [Man 2] Okay. – And then, you know, it’s… – [Man 2] What do you do to fix that? – Remember when, remember
when we talked about when your arm comes up to top, if it doesn’t make it,
you pinch on the tendon and you pinch on the
tendon, I said finally, if you have a rope with two rocks, well that’s what an impingement is. You’re squeezing that tendon. Sometimes you get a spur
there and the doc will take that spur off, but
they still have pain, because now they’re banging that bone up against the denuded area. Because the that had
happened, they lost motion. Hadn’t been rectified yet and until we get that ball in that armpit and ducking away from that roof so it
doesn’t pinch in the top, then it can go away. The surgery doesn’t
necessarily correct the mechanical impingement, just
the pathological, the spur. So we just need to get
you more mechanical. – If you try, like I
was saying right here, if you’re missing any of these things, you can get pain. If you don’t have range of motion and you try to use your shoulder, it’ll hurt whether you have
a rotator cuff tear or not. If you don’t have the strength and you’re trying to lift something you don’t have the strength for, you can
hurt your shoulder like that. If you’re throwing a
baseball the wrong way, if you’re lifting your arm the wrong way, if you’re reaching behind
the back the wrong way, any of those can give you pain. Whether there’s a rotator cuff tear, sometimes there is, sometimes there isn’t. Sometimes there’s a labral
tear, sometimes there isn’t. But, if you…
– [Man 2] If I can just persist, I’m sorry at he
expense of other people, who I’m sure have got questions. If the MRI says that you
haven’t got rotator cuff (audience member coughing over question) Can you really be rest
assured that you really don’t have a rotator
cuff, at least, almost certainly something else? – I would say you probably
don’t have a rotator cuff tear. You may have a neck problem
giving you shoulder pain. You can have a cervical disc
could give you shoulder pain. Though again, that’s the kind of thing that I’m looking at when I do my exam. And when I talk to you, I know that. And I can’t emphasize how
important these guys are. I would say 90% of the
patients that I see, and I examine them, are coming
to me for shoulder pain. And it is a real shoulder pain, that loss of motion
and they don’t know it, until you point it out to them. You know, I’ve been dealing
with this for a year and I haven’t realized
that I can’t move my arm. But I think if you have a normal MRI, you probably don’t have
a rotator cuff pathology. – [Woman] Would you say
that again, 90% of… – Of the patients that I
see with shoulder pain, that have had it for a little bit of time, have lost motion and don’t realize it until I point it out to them. You know, I measure one arm behind their back against the other. Rotation of one arm against the other. I lay them flat on the table. The pitchers are the worst,
you know, the throwers, the tennis players that
come in with a shoulder pain and like Gary said, they’ve lost, the first thing they can
lose is internal rotation. And in your throwing, your pitching, you’ve got to come forward like this and your arm stops, it
doesn’t go any further. And that just jams everything up inside and the mechanics are off. And I send them to physical therapy, say this is all you need
is physical therapy. And they come back and they say, “You know, I thought you were crazy, “sending me to physical therapy. “You were just blowing me off. “But that stuff really works!” If you restore the mechanics,
the pain is going to go away. – That same question. Remember the man that last week said they didn’t find anything
and I’m sad because my shoulder hurts and
they didn’t find anything? That’s good. You don’t
want to find anything. They’re looking for bad
stuff. Bad, bad stuff. If you don’t need to get that
stuff, that’s in your favor. – Yes. – [Man 3] You’re a surgeon, correct? – Yes. – [Man 3] You ever get surprised once you make the hole and look in there? (audience laughing) – Not really. I mean, I
may see something else. But between the exam and the MRI… – [Man 3] You’re pretty
well sure of what you’re doing before that hole gets made? – Yeah. – My tear didn’t show up on MRI either, and they did an arthrogram
and that’s when he saw. He knew I had a tear,
but he didn’t realize it was a full thickness, which it was, so that’s something different.
– [Br. Busch] That’s true, but he was smart enough to say, you know this looks, acts, and
smells like a cuff tear. I just can’t prove it.
– [Woman 2] Right. – You do the next test. You know, for those who don’t know, an arthrogram is where they
inject dye into your shoulder, so it’s a needle, I don’t
know whether he did it MR arthrogram, where they
inject the special dye and then do the MRI, or
just a regular arthrogram, but that would be the
next step if, you know, like I said, if it looks,
acts, and smells like it, you don’t see it, That’s what you do.
– [Woman 2] Yeah, and that’s why he did that. – [Woman 3] Do you
suggest physical therapy prior to surgery? And would that make the condition worse? – I can answer that one. No.
(audience laughing) – [Woman 3] No to what? (laughing) – No, it won’t make it worse. Remember the range of
motion, he said there are different ways of having
a range of motion? If I pick my arm up with
that supraspinitus tendon pulling to lift my arm up, you know how you hold a baseball bat on the end and it’s hard to hold it? Well this little tendons
way up here has to help turn that big arm underneath there. We wouldn’t do weight training with that, but because we know it’s got a tear in it, we will now do all the
passive range of motion so that we have all passively, it’s folding back on
itself, folding on itself, can’t injure it, it’s
the same thing we’ll do the day after surgery. We won’t have you try to
pick up and ruin your repair. We’ll pick it up passively,
fold it back on itself, keeping the range, getting the six weeks, getting the healing and then eventually start letting it get strong. So there’s things we wouldn’t do. With the MRI we actually
know exactly what not to do, because we know exactly
what’s torn and what’s not. – [Woman 3] So I guess,
the thing is, is that would after surgery then, would you have a better chance of recovering faster? If you had…
– Just like the athlete. If we can get that motion,
and back in the old days, when insurances were a
little more compatible to what we wanted to do, that’s
what we did all the time. – [Woman 3] Okay. – Now, it kinda depends on,
and the doctors will do it, you try it, you don’t try. We’ll send you to physical therapy. If you do well, bless you. We didn’t find anything MRI. we found something, let’s get your ready. If you were an, if he saw an ACL, you’ve heard of the ACL, you’ve heard of the ACL tear in athletes. When I get ’em, when they feel
like they don’t need surgery, then we get surgery. ‘Cause then they’re ready. – Let me just expand on that a little bit. When I talk to my patients, I tell them day zero of you rehab
isn’t the day of surgery. Day zero is six months earlier, when you stopped using
your shoulder because it hurt you too much and
those muscles atrophied. And the capsular ligaments contracted and you lost your range of motion. I would love to send everyone
to physical therapy pre-op. Unfortunately, the practical issue is most insurances won’t pay for it. Or you may have a cap on the
number of therapies allowed. You’re only allowed 30 per
year or 30 in a lifetime. And I’ve actually said
to a couple patients that have used up all
their physical therapy, either you’re gonna pay
for therapy yourself, or I’m not gonna do your surgery, because you’re not gonna get better. – [Woman 3] So check with
your insurance first, see what they take care of. – Well, we do that as
part of, but day zero of your rehab is not the
surgery, it’s when your symptoms first started
and you stopped using it. – [Man 4] What if you can’t get an MRI? – [Dr. Busch] There’s problems. You have to have some discussions as to what you’re gonna do and
what your expectations are. – I had a gentleman
because of a health issue and couldn’t have one done. And it was so obvious
there was something there, the doctor did a diagnostic arthroscope. Means he looked in, he
signed if there’s a tear, I’m gonna fix it. Looked in, found a tear,
fixed it, came out. – You asking for insurance issues or? – [Man 4] No, because I
had a pacemaker put in. – We could do an arthrogram
where we inject the dye. I thought you were asking if the insurance doesn’t pay for it. – [Man 4] No. – Fairly active, lift weights no problem. Bench press, overhead
press, lateral raises. A lot of gardening, a lot
of digging, a lot of hoeing. Every now and then I get
ache in the shoulders. Not a pain, but aching. What could that be? – Well, we’re gonna have a little bit of a screen thing down in the back. If you find me down there,
I’ll tell you what I think. (audience laughing) – Yes. – [Man 5] You go.
– [Woman 4] Go ahead. (laughing) Is it possible to
restore range of movement, strength, for a full
tear in your rotator cuff with just physical therapy? That’s how I approached it
and I’m four weeks into it and it’s doing pretty well.
– [Dr. Busch] You can do pretty well.
– [Woman 4] Okay. – [Dr. Busch] You may not
get all your strength back, but certainly a functional.
– [Woman 4] Okay. – It depends how big your tear is. – [Woman 4] Well, full
thickness tear and partial tear in the biceps tendon and shredded labrum. And actually the pain’s really just coming from the biceps tendon. – Do you know what that is? – [Woman 4] What’s that? – Do you know why that is?
– [Woman 4] No. – Because your bicep tendon is making believe it’s a supraspinatus tendon. It really is, it’s trying to be a depressor of your shoulder. He said it has to hold it
down while the arm comes up. Well it ends up getting, remember we said it’ll do it, you’ll over use
it, but it’ll finally fail. And that’s what happened. – I have a, I always think,
we get a bunch of guys from Northwestern, like farmers and stuff. And a lot of those guys have had rotator cuff tears for like 20 years. You know, every once in
a while they’ll come in and will be like, ah, I’ve got
a rotator cuff 20 years ago. Check my arms out. I’m
pushing and pushing. I can’t, they’re stronger than me. And they’re like, I get
some pain once in a while, just give me a couple
exercises, I’ll do them at home. Full thickness tears on both shoulders, they’re still working on the farm. – [Woman 4] Well that’s good to know, so building up those other muscles. – There’s couple motions,
especially what we call external rotation, where you’re pushing your arm out this way. If your rotator cuff
mostly does that motion, but all the other motions,
if you do it long enough and you keep the pain level down and you make sure you keep your range of motion, your other muscles will usually
make up for most of those, eventually.
– [Woman 4] I like that answer (audience laughing) – [Woman 5] (mumbles) So
if you have a partial tear and you do the and then you,
you’re a mild exerciser. You’re a walker or a
swimmer, a mild swimmer. I mean I have this visual,
I’m visualizing like a piece of paper that had partially torn. It’s gonna tear more easily. You know like anything, like reaching, it’s gonna make it tear
faster, is that true? Or is that, I mean are
you more like (mumbles) an acute injury, falling or something. Do you just go back to
your daily business and use sort of mild type of activity. – Well the swimming, swimming can be hard on your
shoulder because it’s overhead. – [Woman 5] Yeah. – So, you’re pinching
again, like Gary said. Anything overhead is gonna aggravate you and if you’re continually doing it. – [Woman 5] When you say aggravate, you’re more likely to
tear it or it hurts more? – If I can add to that.
– [Woman 5] Yeah. – Something happened to
cause your partial tear. Swimming doesn’t cause partial tears. If it did then everybody that
swam would have partial tears, and I’ve got guys that are in
the 90s and they’re swimming. So something’s different on you. Something range of
motion-wise isn’t right. And you’re swimming as much
as you think correctly, remember Jared talked about the form, you’re doing something wrong. If you continue swimming
wrong long enough, you will continue to shred that tendon. If you get it taken care
of and then make it right, you can probably swim
like the 90 year old. You need to make a change in something, because it’s already giving you, the pain is a messenger. He’s giving you a message
you’re doing it wrong. Or swimming would’t do that to you. – [Woman 5] Once it starts
to tear off the bone though, does it make it more
receptive to tearing more? – If you’re, I have a
50% tear from bicycle wreck out in Utah. My sons did this to me. (audience laughing) Went over the handle bars, that
forward roll kind of thing, and when I got it done in
the MRI, I got a 50% tear. If you come up here and lift my shoulder, it makes the worst
sound you’ve ever heard. Do it hurt? No. Do I do all my work? Yes. Am I strong as a bull? Yes. I don’t have a problem with it, because I have all my range of motion, all my strength, that 50% is suffice. You need to know that you’ve
got to make some changes and then you can probably
continue what you want to do. – Yes. – [Woman 6] In a complex
or compounded situation, when you know you have a cervical spine, a herniation or bulge or something, and it’s firing up the shoulder and all. Would you ever treat
both at the same time? Or once you find out what’s
like, say, the prior issue or the secondary issue,
could you or would you treat both at the same time? – You wouldn’t treat surgically
for both at the same time, but you would certainly
treat physical therapy, injections at the same time. – Remember when I said the drawing here? If this, remember when my son was picking his shoulder up like an airplane? That’s because of these
muscles going up here. If I pick my arm up and I’m pinching this, the way to get that out of there is to move the roof out of the way. That’s why the end up making
this substitution. (mumbles) They’re using this muscle, that puts all kind of stress on the cervical spine. There isn’t any time that
you come in the place, if you’ve got a shoulder problem, I wouldn’t treat your neck. If you come in here with a neck problem, I wouldn’t look at your shoulder. Because it’s a joint above and below, they have stress forces relationship, and so I would do them both. Even if you didn’t have a history of it. – Yes. – [Woman 7] Can your sleeping position cause a problem of range of motion that would give you some
pain in your shoulder? – [Dr. Busch] I don’t
think it could give you a problem with range of motion, but the people that sleep with their arms over their head are impinging. – [Woman 7] So they’re
causing impingement. – Yes. – And they’re sleeping
in the impinged position. It’s not good to be in the
end of any range. Alright? But as far as taking a
different look at your question, when people have surgery, they ask me what position should I sleep in? I don’t want to lose any of my motion. Get sleep. Whatever position’s
comfortable is probably the correct position and
won’t injure anything. Initially you’re gonna wear
a sling if you have one on. Later, when you come out
of it, you’re gonna wish you had the sling, because you’re gonna feel naked without it. But without that sling, get any position that’s comfortable
and you’re safe. We don’t try to change range of motion in your sleep position. If your arm hurts when you’re laying in a position at nighttime,
it isn’t from the position. It’s from the fact you don’t have enough range of motion to sleep in that position, therefore your pinching yourself. – [Woman 7] So it’s
still, I mean the sleeping is just showing you.
– [Gary] that you’ve got something else wrong. – [Woman 7] That you’ve
got something, it’s not… – It’s that messenger,
that pain’s a messenger saying you’ve got something, that you lost the motion.
(bouncy music)

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