Frozen Shoulder/Adhesive Capsulitis

By Carla Cranbury, PT

What is it?

Frozen shoulder, also called adhesive capsulitis, is a gradual onset shoulder condition characterized by pain and limited range of motion. This is caused by inflammation and tightening of the shoulder capsule. Typical initial symptoms are pain midway between the shoulder and the elbow and difficulty reaching behind the back. Most women will report that they have difficulty doing up their bra and men difficulty putting on their belt.

Why does it happen?

Limited research has been able to discern one certain cause of frozen shoulder – in short, we don’t know. We do know that it is most common in middle aged women (aged 40-65) and people with diabetes. It also is more likely to occur after a virus, a lingering shoulder injury or after shoulder or upper limb surgery.

How long does it take?

Frozen shoulder goes through three main stages, each of which can take weeks to months:

• Freezing – pain is noticed and range of motion becomes progressively limited
• Frozen – pain is reduced, but range of motion is further restricted
• Thawing – pain is reduced and range of motion gradually returns

Can physio help?

Physiotherapy cannot speed up the course of the condition – everyone has to go through each of the three stages in order to recover. The total process of frozen shoulder can take one to two years to resolve.

What physio can do is help you retain function while going through frozen shoulder, decrease some pain, and ensure a full recovery. Maintaining mobility through the process is important and is where physiotherapy can help the most. Physio will also help prevent other injuries that can be caused by compensating for the frozen shoulder – this is especially significant as it is common for the other shoulder to get the same condition.

Your physiotherapist will give you exercises to maintain as much movement as possible and instruct you on how to perform them properly to ensure you are not compensating for the limited range of motion. Hands on manual therapy will help stretch out the capsule to make the exercises easier to perform. Modalities such as ice, heat, TENS, and acupuncture can also be used to decrease pain.

Though frozen shoulder can be a lengthy and frustrating process, the right care can make it more manageable and prevent any further complications.

 

Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4:193–6.[PubMed]

Greene WB. Essentials of musculoskeletal care. 2. Rosemont, IL: American Academy of Orthopedic Surgeons; 2001

Pal B, Anderson J, Dick WC, Griffiths ID. Limitation of joint mobility and shoulder capsulitis in insulin- and non-insulin dependent diabetes mellitus. Br J Rheumatol. 1986;25:147–51. doi: 10.1093/rheumatology/25.2.147. [PubMed] [Cross Ref]

Bridgman JF. Periarthrits of the shoulder in diabetes mellitus. Ann Rheum Dis. 1972;74:738–46.

Hazleman BL. Frozen shoulder. In: Rockwood CA Jr, Matsen FA III, editors. The shoulder. 2. WB Saunders: Philadelphia; 1990.

Harryman DT, Lazurus MD, Rozencwaig R. The stiff shoulder. In: Rockwood Cam Matsen FA, Wirth MA, Lippitt SB, editors. The shoulder. 3. Saunders: Philadephia; 2004.

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Exercises and Strategies for Stair Climb Events

Stair climbing is both a functional activity that most people complete daily and an activity that can be used for exercise. There are two different strategies that can be used to climb a flight of stairs: the knee first strategy (Figure 1) and the hip first strategy (Figure 2). In the knee first strategy, the movement is broken up into two distinct vectors with a horizontal vector (1) initiating the movement and the vertical component (2) following. This movement pattern relies on the quadriceps muscles as the primary mover and places increased stress on the knee which increases the likelihood of knee pain developing during stair climbing. The hip first strategy combines the vertical and horizontal components and results in a diagonal vector of movement. It relies primarily on the gluteal muscles to initiate the movement. This strategy decreases loading through the knee and reduces the risk of knee pain with repetitive stair climbing. Using a hip first strategy becomes especially important when using stair climbing as an exercise or when training for/completing an event like the CN Tower Climb.

Excellent strength and endurance of the gluteals (buttocks), quadriceps (front thigh muscles), and core are required to successfully complete the CN Tower Climb without injury. A good preparation program will involve both strengthening exercises and stretches for the major muscle groups of the lower extremity and core.

Strengthening Exercises

As the CN Tower climb requires good muscle endurance, each exercise should be performed for a minimum of 20 repetitions.

Squats

Stand with feet hip width apart, toes facing forward. Keeping the chest open and shins vertical, reach the hips back as if sitting on a chair, allowing the knees to bend. The knees should never go in front of the toes.

 

 

 

 

Single Leg Squats

Stand on one leg, keeping the pelvis level. Keeping the knee in line with toes and maintaining a level pelvis, reach the hips back and allow the knee to bend as if sitting on a chair. The knee should never go in front of the toe.

 

 

 

 

Step Ups

Put one leg up onto a step. Keep the knee in line with the toe and drive through the glute to straighten the knee and hip. Weight should not shift forward prior to initiating the movement.

 

 

 

Monster Walks

Stand on a band and cross it in front or tie the band around mid thigh as shown in the picture. Do a mini squat, ensuring that the hips are back and knees are behind toes. Keep the pelvis square and level and take a step to one side, slowly bring the other leg in. Perform to both sides.

 

 

 

 

Plank

With forearms shoulder width apart, gently squeeze shoulder blades together and pull down from ears. Balance on knees (easier) or balls of feet (harder), keeping the spine long, hips in line with shoulders, and chin tucked. Hold 30-60 seconds.

 

Single Leg Jump

Stand on one leg, keeping the pelvis level. Do a mini squat, power through glutes and calf to jump off ground. When landing, ensure heel is on the ground, knee is bent, hip is back and knee is in line with toe.

Box Jump

Stand with feet hip width apart a comfortable distance from the box. Do a mini squat before powering through glutes and swinging arms up to jump onto the box. Land keeping knees behind toes and core engaged. Stand up straight. Jump off the box and land in a controlled squat.

Sprint

With good running form, sprint for 60 seconds. Walk or lightly jog to recover for 2-3 minutes. Repeat 5-8 cycles.

Stretches

All stretches should be held for 30-60 seconds and repeated twice. Stretches should be performed daily when trying to lengthen a muscle or after a work-out when the goal is to maintain muscle length.

Hip Flexors

In a lunge stance with the back knee on the floor, tuck the pelvis under keeping the back straight.

 

 

Glutes

Lying on your back, keeping shoulders and back on the floor, cross the leg to be stretched over the other in a figure 4 position and bring both hips to a 90 degree angle.

 

 

Hamstrings

Sit with the leg to be stretched straight and the other foot tucked in. Keep the back straight and lean forward towards the straight leg by hinging at the hips.

 

 

Quadriceps

Stand and bring the heel of the leg to be stretched towards the buttock. Ensure that the bent knee does not drift forward in front of the other knee.

 

 

 

Calves (Soleus and Gastrocnemius)

Soleus

Stand in a lunge stance. Keeping the torso

upright, bend both knees and sit back over the back leg.

 

 

Gastrocnemius

Stand in a lunge stance. Keep the back leg straight and bend the front leg keeping the back heel on the ground.

 

 

 

Child’s Pose

Start on hands and knees with hands and knees shoulder and hip width apart, keep hands on the ground and sit hips back towards the heels until a stretch is felt through the back.

Injury Prevention and Physiotherapy

By Cassandra Kroner, PT

It is a common misconception that you only need to see a physiotherapist if you have an injury or pain. Physiotherapists have a wide range of skills, and recognizing the risk for future injury is one of them. Injury prevention is applicable to all individuals, regardless of their activity level, from the office worker to the athlete, and especially for those with previous injuries that could reoccur.

Repetitive Strain Factors

• Occupation
• Training errors
• Age
• Excessive or repetitive loads
• Inappropriate footwear
• Structural abnormalities
• Muscle control
• Core stability
• Joint alignment
• Muscle strength and flexibility imbalances
• Previous injury
• Posture

In general there are two types of injuries – traumatic and repetitive strain. Traumatic injuries are easier to understand, as they are the result of a singular event that causes damage. On the other hand, repetitive strain injuries occur when stressors that normally do not cause harm are repeated to the point of causing micro trauma that builds over time until the tissue becomes inflamed and injured. These injuries tend to begin subtly, and gradually increase in severity. Combined with the multi-factorial list of possible contributing factors, repetitive strain injuries can be challenging to diagnose and treat. However, in most cases repetitive strain injuries can be avoided with a good injury prevention and maintenance program.

A Common Factor: Muscle Imbalance

When an individual is involved in one specific sport or has a repetitive aspect to their job, the muscles are put under a great deal of strain to repeatedly perform the same movements. Sedentary jobs involving prolonged postures can have similar effects with certain muscles constantly working for long periods. Over time, muscle imbalances develop as the muscles that are being used the most continue to get strong while the reciprocating muscles become lengthened and weak. These muscle imbalances can cause movement restrictions that affect performance and increase stress on the body. Increased stress on muscles, joints and ligaments eventually leads to a repetitive strain injury.

The First Steps Toward Injury Prevention

Getting started on the road to injury prevention is as simple as booking an appointment with a physiotherapist. If you are unsure how injury prevention could apply to you or if you could be at risk for injury, speaking with a physiotherapist can help clarify your needs and goals. The same expert assessment skills physiotherapists use to diagnose injury will be used to proactively assess for risk factors that could lead to future injury. Your lifestyle, the demands of your job, and the specific sports or activities you participate in will be considered, along with the assessment findings, to develop an individualized treatment plan. This plan could involve manual therapy to correct joint restrictions or muscle length imbalance, strength and flexibility exercises, correction of movement patterns, and education.

By addressing several predisposing factors to injury, the body is optimally prepared to handle the demands of the workplace or sport. This can translate to decreased frequency and severity of future injuries, with the added benefit of a shortened recovery time in the event an injury does occur. Don’t wait for an injury to strike to take charge of your health!

The Sitting Solution

By Carla Cranbury, PT

Let’s face it, we sit a lot. Between working, commuting, and watching television, the Canada Health Measures Survey found that most Canadian adults spend 9 hours and 48 minutes of their waking time being sedentary. Most of us know that physical activity is good for us, but did you know that just sitting less (regardless of exercise) can also be beneficial in the long term?

A study published in 2009 followed more than 17 000 Canadians for 12 years. Over the twelve years they compared the participants’ daily sitting time and leisure time physical activity with mortality rates of various causes. What they found was that the amount of daily sitting time was positively associated with mortality rates from all causes, except cancer. Basically the more people sit, the higher the risk of mortality. This even includes people who are physically active, showing that high amounts of sitting time cannot be compensated for with exercise, even if it exceeds the current minimum physical activity recommendations.

Other studies have echoed similar findings. A seven year study reported that people who spend less than half their time sitting have a lower risk of mortality than those who spend more than half their day sitting. Another six year study reported that women who spend 16+ hours sitting per day have an elevated risk for cardiovascular disease compared with women who sit for less than 4 hours a day.

These studies are not to say that physical activity is not important – it still is, and it is still beneficial for your health. Physical activity also contributes to decreased time spent sitting.  What these studies are saying is the physiology associated with excessive sitting is different than the physiological benefits of exercise, and therefore excessive sitting cannot be compensated for with periods of exercise.

So now that you know, what can you do?

If you work at a desk most of the day, sitting can be hard to avoid. Some options are:

• Ask your work if they can accommodate an ergonomically sound standing desk
• Take frequent breaks from sitting to walk around
• Go for a walk on your lunch break
• Walk to your co-workers desk to talk to them instead of sending an email
• Park at the back of the parking lot to get a few extra steps
• Take the stairs!
• Take frequent standing breaks throughout the day
• Discover new ways to be active during your leisure time – ditch the TV and get outside

It’s the small changes to your daily routine that can add up and make a big difference. The best time to start is today!

References

Katzmarzyk, Peter T. et al. “Sitting Time And Mortality From All Causes, Cardiovascular Disease, And Cancer”. Medicine & Science in Sports & Exercise 41.5 (2009): 998-1005. Web.

“Directly Measured Physical Activity Of Adults, 2012 And 2013”. Statcan.gc.ca. N.p., 2017. Web.

Manson, J.E., P. Greenland, and A.Z. LaCroix. “Walking Compared With Vigorous Exercise For The Prevention Of Cardiovascular Events In Women”. ACC Current Journal Review 12.1 (2003): 29. Web.

Weller, Iris and Paul Corey. “The Impact Of Excluding Non-Leisure Energy Expenditure On The Relation Between Physical Activity And Mortality In Women”. Epidemiology 9.6 (1998): 632-635. Web.

Why dancers need the perfect balance of strength and flexibility

By Kelsey Jack, PT

My ballet teacher once told me that given a choice between having strength and flexibility, she would choose strength. This has always stuck with me as there is such an emphasis on flexibility within the dance world that often there is a lack of focus on building the strength required to make use of that flexibility. This enhanced focus on flexibility instead of a balance between strength and flexibility creates muscle imbalances. If dancers work to improve their flexibility and ignore balancing the strength around the joints, it leaves the dancer vulnerable to injury.

Why is balancing strength and flexibility important?

Stability is provided to joints from a combination of passive and active structures. Passive structures include the bones that make up the joint and the ligaments that surround it and support it. Active structures are the muscles and tendons that act to both maintain stability and move the joint. Focusing on passive, static stretching, as is often the case in dance, can lead to instability of joints as the ligaments that are meant to stabilize the joint become stretched out and no longer provide joint support.

Flexibility, or range of motion can be divided into two categories: passive and active. Passive range of motion is demonstrated by how high a dancer is able to lift their leg using their hands whereas active range of motion is how high a dancer is able to lift their leg using their hip muscles and is demonstrated by doing a step like a developpé.  Practically speaking, flexibility without strength limits active range of motion and will hinder the height of legs when performing steps that involve controlled movements and sustained positions.

Back bends are a good example of a movement that is common in dance where strength is required to balance the flexibility of the spine. Dancers without good core strength and control will hinge through their spine, relying on one or two segments to gain all of their movement through. This leaves the spine vulnerable to injury as the ligaments and discs are relied on for support. Ideally when doing a back bend the spine should form a “C” curve. Many teachers instruct dancers to breathe up and extend through the top of their head into their back bend to encourage control into this movement pattern. Engagement of the abdominals and stabilizer muscles of the spine are required to move through each segment of the spine in a way that supports the passive structures of the back to create the desired curve.  It is subtle differences such as these in how a dancer moves, using strength to control their flexibility, that improves the quality of movement and decrease the future risk of injury.

Evidence to support strengthening to increase flexibility

As dancers are often concerned about their hip flexibility, a study was done looking into the best way to increase hip active range of motion. The researchers compared three stretching programs over a six week period. The first group of dancers completed a strengthening program where they worked at strengthening their hip flexors at the end of their available range of motion. The second group completed a “light” stretching program for their gluteals, hamstrings, calves, and quadriceps muscles, holding each stretch for 1 minute. This group was asked to perform stretches at an intensity of 3/10 on a scale where 0 is no stretch and 10 is an intense stretch that elicits a burning sensation. The third group performed the same stretches but at a “moderate-high” intensity which was rated as 8/10 on the same scale. The study found that all three groups had an increase in their passive range of motion but only the strength training and the low intensity stretching groups improved their active range of motion. The strengthening group saw the greatest improvements in both passive and active range of motion which is explained by the hamstrings relaxing as the hip flexor is contracted. This allows the hamstring to lengthen while the hip flexor is strengthened. Intense stretching without strengthening (as in the high intensity group) leads to lengthened, weakened muscles which functionally hinder a dancer’s ability to make use of their range of motion. This study demonstrates that exercises that specifically train the hip flexors progress flexibility in a way that translates into dance.

Strengthening allows dancers to maximize their flexibility without compromising the integrity of their passive support structures and increasing their risk of injury. A physiotherapist can assess a dancer’s strength and flexibility and develop a program that will safely allow a dancer to increase their flexibility while strengthening the muscles needed to support their joints, improve performance, and decrease risk of future injury.

References:

Wyon MA, Smith A, Koutedakis Y. A Comparison of Strength and Stretch Interventions on Active and Passive Ranges of Movement in Dancers: A Randomized Controlled Trial. Journal of Strength and Conditioning Research. 2013. 27(11)3053.

How Physiotherapy Can Help With Osteoporosis

By Lana Kovacevic, PT

Osteoporosis is a condition of reduced bone strength that causes bones to be more likely to break (1). It is a progressive disease in which the density and quality of bone decreases over time making it more fragile. Current trends show that more and more people are affected by osteoporosis each year (1). Among Canadian men and women, an estimated 1 in 4 women have osteoporosis compared to 1 in 8 men (1).

Why is osteoporosis so concerning?

The major threat to healthy aging and independent mobility for those with osteoporosis is the risk of sustaining a fragility fracture. A fragility fracture is a broken bone that results from minimal trauma or stress – stress which typically would not cause a bone to break (1). An example would be breaking a bone in the wrist or hip after falling from standing height (1). After an initial fragility fracture, you become more than two times as likely to sustain another fracture in the future (1). The most common bones to be injured are those of the wrist, upper arm, ribs, spine, pelvis, and hip (1).

Who is at risk for osteoporosis?

Canadian guidelines recommend that all postmenopausal women and men over the age of 50 years be screened for their risk of osteoporosis (1). A diagnosis is made following an X-ray that measures bone mineral density. This test is recommended for those who have at least 1 major or 2 minor risk factors (1).

Figure 1: Some key major and minor risk factors for osteoporosis (1)

Major Risk Factors	Minor Risk Factors
Age over 65 years Family history of osteoporosis fracture Early menopause (before age 45) Glucocorticoid therapy for more than 3 months Falls	Smoking Diet low in calcium Body weight less than 57 kg Rheumatoid arthritis

How can I check if I am at risk for osteoporosis?

A convenient online tool for estimating the risk of osteoporosis fracture exists called the FRAX® Fracture Risk Assessment Tool. Click on this link to get an estimate of your personal risk. If you are concerned about your risk for osteoporosis, it is best to consult your family doctor.

How is osteoporosis treated?

Apart from medical management with medication and supplementation, exercise is a key component of treatment. Exercise has been shown to slow the loss of bone mineral density and reduce the risk of falling (1). This means that exercise can be beneficial for both preventing osteoporosis as well as managing symptoms for those already diagnosed with osteoporosis.

Can physiotherapy and exercise help if…

…I’m concerned about developing osteoporosis in the future?

For anyone at an increased risk of osteoporosis or those with a family history of osteoporosis, taking part in weight-bearing physical activity and activity that involves some impact is best for preventing bone loss. Starting this type of exercise at a younger age may make you less likely to suffer from osteoporosis in older age.

…I’ve already been diagnosed with osteoporosis?

For those with osteoporosis, exercise is important to help minimize bone density loss. It is also critical for reducing the risk of falling and therefore, a broken bone. Risk of falling is higher for people with poor strength, balance, posture, and with poor postural stability. All of these factors can be addressed and improved with a proper exercise program.

…I’ve already had a fragility fracture and want to avoid having another one in the future?

A safe exercise program is also beneficial for those who have already suffered a broken bone associated with osteoporosis. Less than 20% of women (or 1 in 5) and 10% of men (or 1 in 10) who have had a fracture are given the appropriate treatment to prevent a future fracture (2). It is important to restore safe movement patterns during recovery from a fracture as well as to reduce the risk of sustaining another fracture.

Each person is unique and should have an exercise program that is tailored to their specific needs. A physiotherapist can assess, treat, and teach you how to reduce your risk of osteoporosis, manage your symptoms, and improve your general health and physical functioning.

Reference:

1. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002. 167(10); S1-34.
2. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010. 182(17): 1-10.

Shin Splints

Medial tibial stress syndrome, commonly called “shin splints”, is a term used to describe pain and tenderness felt on the inside, lower border of the shin bone. Shin splints are commonly experienced by athletes who take part in activities involving repetitive running and jumping, particularly after a sudden increase in activity level (either duration, distance or intensity). The repetitive stress placed on the bones, muscles and joints of the lower leg during these high impact activities may result in irritation and inflammation of the shin bone (tibia).

Shin splint pain is usually described as a dull ache. It usually develops slowly over time, first being noticed at the end of activity. Some athletes may complain of pain at the beginning and end of activity, but not affecting their performance. Over time, pain will commence during activity and eventually may be felt during regular day to day activities such as walking. As shin splints progress, they also make the lower leg sore to touch.

There are a number of factors that may predispose an athlete to develop shin splints including: flat feet, rigid arches, muscle weakness, and/or muscle tightness. Other contributing factors may include running downhill, running on hard surfaces, running in worn-out footwear, or playing sports with frequent stops and starts (e.g. basketball, squash, tennis). While the pain presentation is often similar across individuals, there are a variety of bio-mechanical abnormalities in the pelvis, hips, knees, and ankles that can also lead to the development of shin splints.

Proper treatment requires a detailed assessment by a registered Physiotherapist to identify and target the contributing factors as well as the location of pain. Treatment includes rest, ice, specific joint mobilizations, an individualized stretching and strengthening program, and if needed a gradual return to regular activity. During recovery, aerobic fitness can be maintained with low impact activities such as swimming and biking. If left untreated, the repetitive stress on the tibia may result in a stress fracture yielding a longer recovery time.

A physiotherapist can perform a full assessment to determine the exact cause of an athlete’s pain and develop a treatment program to relieve pain, facilitate return to activity, and prevent future injury.