Proper rotator cuff and scapular muscle strength is critical to preventing and treating shoulder pain.  In this video, I demonstrate one of my favorite rotator cuff and scapular stabilizing exercises using an exercise band.  It works the lower trapezius, deltoid and rotator cuff muscles.

The rotator cuff is a critical component to shoulder mobility.  It’s made up of four different muscles whose job is to make sure that the ball of the humerus (arm bone) rotates, slides, and glides properly in the socket, which is made up of the scapula.  The rotator cuff allows the other major muscles of the arm, such as the deltoid and Latissimus dorsi (lats), to properly perform their movements.

The scapulothoracic muscles are the lower trapezius, middle trapezius and rhomboids primarily and proper strength and function in these muscles is critical to insuring proper shoulder blade movement and general shoulder mechanics.  Weakness in these muscles is often associated with shoulder impingement syndrome.

Weakness in the rotator cuff or scapulothoracic muscles can lead to rubbing of the rotator cuff tendon on the bone or impingement of the bursa within the shoulder leading to impingement syndrome (which can eventually lead to fraying and tearing).  With proper muscle strength and balance, you can help reduce the risk of this occurring.

Shoulder impingement or a partial rotator cuff tear can be very painful and may take many weeks to recover.  Many different causative factors can lead to these conditions.  In most cases, shoulder impingement (or even small partial tears) can be completely rehabilitated and should (when treated properly) leave no residual effects once a person has recovered.

For more information on how to address shoulder impingement, please refer to How Should I Treat Shoulder Pain and Impingement?

For an example of another shoulder exercise that can be helpful in improving rotator cuff and scapulothoracic strength, check out my video on How to Treat Shoulder Pain with an Exercise Band.

In addition to proper rotator cuff strength, it’s important to address adequate shoulder and thoracic (upper back) mobility.  Be sure to check out My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain.  Subscribe and you will automatically gain access to this FREE resource.  Download the .pdf file, which is full of photos and exercise instructions, to get started!

Shoulder pain can be debilitating by limiting your ability to exercise and perform daily tasks.  Be proactive in your care and management.  If you continue to experience pain, seek additional help.  Don’t let the pain linger.  The longer a condition is left untreated, the more potential for harm and damage which potentially could lead to a longer recovery.  The American Physical Therapy Association (APTA) is an excellent resource for learning more about physical therapy as well as locating a physical therapist in your area.

Which treatments have you found to be the most effective in dealing with shoulder pain?  Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Proper rotator cuff and scapular muscle strength is critical to treating shoulder pain.  In this video, I demonstrate one of my favorite rotator cuff strengthening exercises by using an exercise band.  It works both the lower trapezius and rotator cuff.

The rotator cuff is a critical component to shoulder mobility.  It’s made up of four different muscles whose job is to make sure that the ball of the humerus (arm bone) rotates, slides, and glides properly in the socket, which is made up of the scapula.  The rotator cuff allows the other major muscles of the arm, such as the deltoid and Latissimus dorsi (lats), to properly perform their movements.

When there is weakness or dysfunction, it will cause rubbing of the muscle tendon on the bone–leading to impingement or eventually fraying and tearing.  With proper muscle strength and balance you can help reduce the risk of this occurring.

Shoulder impingement or a partial rotator cuff tear can be very painful and may take many weeks to recover.  Many different causative factors can lead to these conditions.  In most cases, shoulder impingement (or even small partial tears) can be completely rehabilitated and should (when treated properly) leave no residual effects once a person has recovered.  For more information on how to address shoulder impingement, please refer to How Should I Treat Shoulder Pain and Impingement?

In addition to proper rotator cuff strength, it’s important to address adequate shoulder and thoracic (upper back) mobility.  Be sure to check out My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain.  By subscribing to my e-mail list, you will automatically gain access to this FREE resource.  Download the .pdf file, which is full of photos and exercise instructions, to get started!

Shoulder pain can be debilitating by limiting your ability to exercise and perform daily tasks.  Be proactive in your care and management.  If you continue to experience pain, seek additional help.  Don’t let the pain linger.  The longer a condition is left untreated, the more potential for harm and damage which potentially could lead to a longer recovery.  The American Physical Therapy Association (APTA) is an excellent resource for learning more about physical therapy as well as locating a physical therapist in your area.

Which treatments have you found to be the most effective in dealing with shoulder pain?  Additional discussion can help others to manage his/her pain.  Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com. Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

How rehabilitation progresses will vary greatly for each individual.  Therefore, no treatment plan will be alike.  For discussion purposes, I will address a generic treatment plan, which should be modified for your personal needs and activity level.  In this final stage of rehabilitation, you will progress to normal daily activities, including any athletic endeavors.  This is also when you work toward limiting any future reoccurrences of the sprain.

At this stage in recovering from a lateral ankle sprain, you should be walking relatively normally and mostly pain-free.  Running and more active side-to-side movements likely still cause pain.  Although not contra-indicated, these types of activities should be limited (unless you’re wearing a good lace up brace or are being regularly taped by a professional).

The initial portion of the rehabilitation is centered on improving ankle and foot strength, stability, as well as addressing any balance deficits.  This process begins with statically based exercises and activities.  Ultimately, it progresses into dynamic strength, balance, and mobility activities.  How rapidly a person progresses in this phase is wildly variable.  The key is to progress at your own pace.  If you start experiencing increasing pain, feelings of ankle instability, and sensations that it may “roll” or sprain again, then you need to taper down your activity level.  After the pain subsides, continue to focus on the activities that that didn’t cause pain or discomfort previously.

The following treatment plan includes exercises for strength and balance as well as mobility drills and full athletic simulation drills.  Each category is listed in an easiest to most challenging format.  You shouldn’t progress to the next exercise until the first one is mastered.

Strength

• Heel/Toe Raises – A person should be able to perform 25 heel raises in a row with only minimal fingertip assistance on a counter top.  A normal amount of calf strength would be considered once you can perform 25 heel raises. 

• One Leg Squat – Perform a one leg squat without using your hands for balance to increase the difficulty level.  The one leg squat on your tip toes is a harder variation which involves more calf muscle activation.  Start with two sets of 10 repetitions, then progress to three sets of 10 repetitions.

• Clock Exercise – Stand on your affected (injured) foot and attempt to touch your tip toe of the non-affected side as far out as you can reach.  Bring your foot back to the center or starting point according to the hands on a clock.  For example, 1 o’clock to 6 o’clock (clock-wise) or 12 ‘o clock to 6 o’ clock (counter clock-wise) depending on which foot is affected.  Perform the routine between three to five times slowly.

Balance

• Stand on one foot – A 30 second hold with eyes open during the first time, then closed during the second time, is considered normal.
• Stand on one foot on a pillow – A 30 second hold for two to three repetitions.  As you progress, stand on the pillow and perform the Clock Exercise as described above.
• Stand on one foot and bounce a ball against a wall.
• Stand on a Wobble Board, Bosu Balance Trainer or other unstable surface.

Mobility Drills

• Initially, start with forward and backward movements and progress from a walk, to a jog, to a sprint.
• Jump Rope
• Side Stepping – Progress the speed as pain allows and if you’re not experiencing the feeling of instability.
• Karaoke or Grapevine – Walk or run sideways while alternating the placement of the foot either in front or behind the other.
• Sprint Ladder – A number of agility drills can be performed with the sprint ladder.  Search YouTube and pick your favorite video which closely mimics the footwork desired for your particular sport or activity.
• Short side-to-side Wind Sprints – While sprinting, touch your hand to the ground at each change of direction.

Full Athletic Simulation Drills

• Depending on your sport of choice, return to your sport specific training drills.  You may still require additional support.  I recommend wearing a good lace up brace or being taped by a professional for support.  Additional support should only be used temporarily and with the intention of progressing from using them as your ankle can tolerate.

If you continue to experience pain and swelling, and/or require an accelerated time table for recovery (or return to competition), then I recommend the services of a sports medicine physical therapist or athletic trainer.  Many modalities, such as electrical stimulation, manual techniques and taping methods can assist in recovery when properly utilized.  To find a qualified physical therapist in your area, search at American Physical Therapy Association (APTA).

Depending on your time table for recovery and the severity of your injury, the information provided in this three part series on ankle sprains will likely be very helpful in your recovery.  Each person and injury is different.  If you’re interested in a more complete and comprehensive look at self-rehabilitating an ankle sprain, be sure to check out Treating Ankle Sprains and Strains.

Knowing how to effectively self-treat and manage ankle sprains and strains is important in order to resume your training and normal activities without the risk of additional damage, injury or re-injury.  When you can confidently self-treat, you can limit pain levels, return to activity faster, and prevent reoccurrences.

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In my book, Treating Ankle Sprains and Strains, you will learn how to safely and confidently self-rehabilitate a common ankle sprain.  It will guide you through the ins and outs of self-treating your ankle so you can avoid costly rehabilitation bills.  Beginning with the acute phase of rehabilitation, I will walk you through the treatment plan on how to rehabilitate your ankle through the intermediate (sub-acute) phase of rehabilitation and return to full activity and sport.

Learn how to safely self-treat and properly rehabilitate your ankle so you can get back to your daily life and exercise goals more quickly without additional costly medical bills!

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Sprains are categorized as Grade I, II, or III.  A Grade I sprain is the most common.  It’s typically associated with only mild damage to the ligament, and instability doesn’t affect the joint.  A Grade II sprain is a partial tear to the ligament and is usually associated with some laxity (hypermobility).  If this occurs, it’s best to wear a brace for several weeks.  Ideally, scar tissue will form and compensate for the lax ligament, so the joint doesn’t become hypermobile.  Good muscle strength and proprioception of the lower foot is important to limit future sprains.  In Grade III sprains, a full tear of the ligament occurred.  One typically consults with an orthopaedic surgeon for possible repair.  After surgery, a guided physical therapy program is recommended.

For discussion purposes, I will only address a Grade I sprain.  Initially, one may wear an air splint, ACE wrap, or some other lace-up or slip-on style brace to help with stability, inflammation, and pain control of the ankle.  In most cases, a person will want to transition from wearing the brace as soon as the initial pain subsides.  (If one had a Grade II sprain, he/she would wear a splint for several weeks so that the ankle would initially stiffen.)

At this point in your recovery, you are likely three to seven days since the initial injury.  This phase of rehabilitation can last from seven days to several weeks before progressing into the final phase of rehabilitation (and ultimately, back to full function).  Progression out of the intermediate phase is always symptom dependent.  You should be able to stand with equal weight on your feet and not experience an increase in ankle pain.  The ankle is likely stiff at this time, but it is time to start walking, progress range of motion (ROM), and start gentle resistive exercises.

Walking

If you have been using a crutch to unweight the foot, then start the progression to weight bearing during walking.  If you have been walking, then increase the amount of weight you have been putting on the ankle and foot.  At this time, the focus will be to normalize your walking pattern.  This means having a good heel strike, rolling onto the foot into full weight bearing on the leg, and then propelling forward with a good toe off.  You will continue to use the crutch as long as needed until you can walk nearly normal without limping.  Until then, utilize the crutch to unweight the leg and foot as much as necessary to perform a nearly normal walk or gait sequence.

Range of Motion (ROM)

Start to increase the range of motion of the ankle.  Initially, work to progress the plantarflexion and dorsiflexion movement (the forward and backward movement of the ankle).  As pain subsides, progress the side to side motion as well as all other motions.

Recommended Exercises:

Ankle Pumps – A very easy exercise.  Just pump your ankle forward and backward into plantarflexion and dorsiflexion movement.  Perform 10-15 repetitions several times a day on both feet.

Ankle Alphabet – Move the foot and ankle only by pretending your big toe is a pen, and draw the alphabet using capital letters.  Perform 1-2 times a day.

Calf Stretching – Hold each stretch for at least 30 seconds, three times on each leg, 2-3 times a day.  This stretch shouldn’t cause more than a mild increase in pain or discomfort.

Gentle Resistive Exercises

Perform plantarflexion and dorsiflexion movement by initially using an exercise band.  I recommend using a Thera-Band Exercise Band.  As your pain improves, you can progress to standing heel and toe raises as long as you don’t experience more than a mild increase in pain levels.

As pain and range of motion improve, progress to inversion and eversion with the exercise band.  Stop if you experience more than a mild increase in pain levels.

Initial Balance and Proprioception Exercise

Stand on one foot. Initially, you may need to use your hand (or a finger) on a counter top for added support.  As the pain subsides and your balance improves, you may need to increase the difficulty level.  As you progress, balance will become of greater importance.

Toward the end of the intermediate phase, you should be walking fairly normally.  There will likely be some swelling.  It’s typical for some amount of swelling to come and go.  It will be directly related to how long you are on your feet and your general lower extremity circulation.  I highly recommend you continue to wear compression stockings during this time.  You may also continue to experience soreness and pain–particularly after a long day or a lot of upright activity.  Continue to utilize a regular icing protocol as needed for pain and swelling.  Also, continue to supplement with CapraFlex.

It’s time to progress into the final stage of rehabilitation once you have returned to near normal walking, your pain levels are relatively low, and you are able to complete the basic exercises listed above.  The final stage of rehabilitation includes a full return to daily activities and eventually, all sport or athletic activities.  I will address the specifics of the final stage of rehabilitation in Part III.

Knowing how to effectively self-treat and manage ankle sprains and strains is important in order to resume your training and normal activities without the risk of additional damage, injury or re-injury.  When you can confidently self-treat, you can limit pain levels, return to activity faster, and prevent reoccurrences.

AVAILABLE NOW ON AMAZON!

In my book, Treating Ankle Sprains and Strains, you will learn how to safely and confidently self-rehabilitate a common ankle sprain.  It will guide you through the ins and outs of self-treating your ankle so you can avoid costly rehabilitation bills.  Beginning with the acute phase of rehabilitation, I will walk you through the treatment plan on how to rehabilitate your ankle through the intermediate (sub-acute) phase of rehabilitation and return to full activity and sport.

Learn how to safely self-treat and properly rehabilitate your ankle so you can get back to your daily life and exercise goals more quickly without additional costly medical bills!

BUY NOW

Poor Mobility

The most common reason for mobility issues is poor posture.  Poor thoracic mobility and tightness in the posterior capsule of the shoulder are the most common contributors to the lack of mobility which can ultimately lead to shoulder pain.

Mobility issues can occur if you adopt a chronic forward head with rounded shoulders posture.  As this position becomes more chronic, the thoracic vertebrae lose backward mobility (extension).  This happens in conjunction with shortening of the pec minor (which is located underneath the pec major) and causes the shoulders to roll forward.  The forward shoulder posture causes the humeral head (arm bone) to be positioned more forward.

This causes tightness in the posterior (back) portion of the shoulder joint which affects the natural roll and spin motion of the joint.  The alterations of the roll and spin motion combined with alterations in shoulder blade motion negatively affects the mechanics of the shoulder joint.  The alteration in mechanics is what ultimately leads to pain as the rotator cuff or biceps tendons become impinged, irritated, and painful.

This is commonly referred to as Shoulder Impingement Syndrome.  Shoulder impingement pain is often associated with pain reaching overhead, behind your back and/or out to the side.  Those who experience it may feel weaker in the affected shoulder and experience pain when sleeping on the affected side.

Perform the following stretch to address shoulder posterior capsule tightness.  Lie on the side of the affected shoulder.  Be sure to support your head with a pillow.  Your arm should be straight out from your body with your shoulder tucked under your body.  The goal is to pin your shoulder blade down with the floor.  Gently push your arm down (as shown).  You should feel a gentle stretch.  Hold for 30-60 seconds for two to three times.  Perform once or twice per day.

In case you haven’t already subscribed to my e-mail list, please take a moment to do so in order to access my FREE resources, including My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain.  It’s a downloadable .pdf file with my recommended stretches and exercises to address poor thoracic mobility and pec minor tightness.  These simple exercises (with complete instructions and photos) will help you to improve thoracic mobility and can be performed at home.

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Muscle Imbalance

Muscle imbalance is often an associated causative factor for shoulder pain.  In addition to mobility issues, altered strength and muscle activation patterns are also related to shoulder pain and shoulder impingement syndrome.  The reasons for muscle imbalance can vary, but are often associated with poor posture and/or cervical/neck related issues.

Two common muscles that must be strengthened in order to insure proper shoulder mechanics are the lower trapezius muscle and the supraspinatus muscle (which is one of four rotator cuff muscles).

The rotator cuff muscles are responsible for the stability of the shoulder and proper roll, glide, and spin of the ball and socket shoulder joint.

The lower trapezius muscle is responsible for proper shoulder blade timing and rotation during arm movements.  It helps in maintaining a proper upright posture.

For three easy and effective exercises to perform to improve your lower trapezius and rotator cuff muscle strength, please refer to Exercises for Lower Trapezius and Rotator Cuff Muscle Strength.

Most shoulder symptoms typically resolve when thoracic mobility and strength in the shoulder is improved.  Shoulder impingement is painful, but worse yet if left untreated.  It can lead to fraying of the rotator cuff tendons (and ultimately, a rotator cuff tear).  It’s always best to be proactive and address the causative factors early.

If you’re not improving or your symptoms worsen, consult with your medical provider to determine if other causes are contributing to the problem.  The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area.  In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

If you’re experiencing shoulder pain, do you think either poor mobility or a muscle imbalance is causing it?  How can you improve your thoracic mobility and strength in your shoulder?  Please share below.

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

A.  Thanks for the question, Shawn. I’m sorry to hear about your snowboarding accident.  Fractures of the collarbone (clavicle) are actually fairly common and typically result from falling on the shoulder, the collarbone or an outstretched hand.  Collarbone injuries are also very common in toddlers, typically due to a fall out of bed or tripping when running.

The collarbone attaches the sternum to the scapula (shoulder blade). Many important structures, such as nerves and blood vessels, lie just below the clavicle. However, these vital structures are rarely injured when the clavicle breaks.  Diagnosing a clavicle fracture is typically performed via X-ray. In certain circumstances, a CT Scan may be performed for a more thorough image of the injury.

Symptoms of a Collarbone Fracture include:

• Pain in the shoulder or over the collarbone.
• Difficulty raising your arm due to pain.
• Slumping or sagging of the shoulder, typically downward and forward.
• A grinding sensation in the collarbone area when attempting to raise the arm.
• A “bump” forms over the collarbone. In severe cases, the bump will be similar to a piano key sticking up and will be mobile.
• Bruising and swelling over the collarbone area.

Surgical Intervention

Depending on the severity of the injury, surgery may or may not be indicated. In most cases, a simple fracture (where the bones are still aligned) will not require surgery.  Even in cases of minor malalignment, most people will not undergo surgery.

Surgical fixation is most common when there is a significant displacement or malalignment present. The purpose of surgical fixation is to hold the bones in place while they heal.  The physician will either utilize a metal plate and screws or small pins to hold the bones in place.  Although the surgical hardware can be removed once the bones have sufficiently healed, often it will remain throughout a person’s lifetime.

Rehabilitation post-surgery is fairly straight forward and is similar to the following nonsurgical treatment recommendations. Please follow your physician’s recommendations after surgery as each procedure can be different.  Variations in recovery and rehabilitation can occur and are dependent on: the area that was fixed; the severity of the fracture; and the stability of the bone and fixation.  These factors will determine how quickly you can progress through the rehabilitation.

Nonsurgical Treatment Recommendations

Most collarbone fractures do not require surgery (particularly, if the fractured area retains its alignment). Your physician will assess the severity of the fracture.  This will determine how quickly you can progress through the stages of treatment.

A general time frame for healing (with an initial return to function) is on average 6 weeks for adults and about 4 weeks for children. Complete bone healing, remodeling, and a full return to all activities will take longer.  This will depend on your age, health status, and the severity of the injury.

PRICE (Protect, Rest, Ice, Compression, and Elevation)

• Protect. In many cases, you will be advised to wear a sling (particularly, during your daily activities). This will help to protect the area from too much motion and activity while allowing the bone to heal in its proper place. It will also indicate to others that you have an injury, so that they may avoid knocking into you.
• Rest. Allow the arm and shoulder time to rest and recover. Do not utilize the arm for activities that cause pain. Avoid excessive motions and use. As the pain subsides, you can slowly taper up the use of the arm by starting with simple daily activities.
• Ice. Apply ice to the painful area–typically the sooner, the better. The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. A bag of frozen peas can be ideal. Individuals with poor circulation or impaired sensation should take particular care when icing.
• Compression. It’s not easy to apply compression in this area. In most cases, it’s not necessary. In some cases, a simple ACE wrap can be used around the shoulder and collarbone area to help reduce the pain. The wrap is typically applied to help hold the shoulder in a backward and slightly downward direction.
• Elevation. Elevation is typically not necessary unless you are experiencing excessive swelling in the affected arm and hand. You can position the arm in a slightly elevated position by using pillows while lying on your back or on the non-affected side. This would be an excellent time to apply ice, too.

Sleeping

When sleeping, try not to lie on the affected side. Hug a small pillow for comfort.  This also promotes optimal blood flow to the shoulder area.

Pain Management

Initially begin with PRICE (Protect, Rest, Ice, Compression, and Elevation).  Pain medication, such as acetaminophen, is always an option if recommended by your physician.  You may also want to consider utilizing topical agents, which can help to decrease pain and muscle spasms. The method of action varies greatly according to the product used. You may find that one product works better than another. Some of my favorite products in my medicine cabinet include: Biofreeze Pain Relieving Gel; Arnica Rub (Arnica Montana, an herbal rub); and topical magnesium.

Another option is oral magnesium. You can take Mag Glycinate in pill form or by eating foods higher in magnesium such as spinach, artichokes, and dates. Taking additional magnesium (particularly at night) can help to reduce muscle cramps and spasming. It is also very helpful in reducing overall muscle soreness and aiding in a better night’s rest. Most people are deficient in the amount of magnesium they consume on a regular basis. I recommend beginning with a dose of 200 mg (before bedtime) and increasing the dose as needed. I would caution you that taking too much magnesium can lead to diarrhea. Mag Glycinate in its oral form is the most highly absorbable. Although not as absorbable, Thorne Research Magnesium Citrate and magnesium oxide can also be beneficial.

Supplements

Mt. Capra, an organic goat farm in eastern Washington State, offers superior quality products primarily utilizing goat based products. CapraFlex by Mt. Capra is the best bone and joint supplement I have found. It is a blend of natural herbs and spices along with glucosamine and chondroitin.  The herbal and spice formulation is designed to naturally decrease inflammation and support healing.  I recommend it to anyone recovering from an injury or attempting to prevent injury when performing at a very high level.  I personally use it, and in my practice, it has helped clients recover faster and prevent injury.  It can interfere with some blood thinning medication, so if you are on this type of medication, please check with your physician.

Vitamin D3, such as Viva Labs Vitamin D3, is critical to the absorption of calcium through the intestinal wall which is important for bone health.  Although calcium is a critical component of bone health, I cannot recommend extra supplementation because of the potential cardiac risks to over supplementation.  A healthy varied diet will typically supply adequate calcium levels (assuming that adequate Vitamin D3 levels are present for absorption and that you are avoiding drinking soda).  Vitamin D3 is also a critical nutrient in maintaining a healthy immune system.

Be sure to maintain a generally healthy diet. Give your body the needed nutrients to heal and recover quickly.

Range of Motion

Depending on the severity of the fracture, you will likely have to limit the range of motion (ROM) of the shoulder to less than 70-80 degrees of flexion (forward) and abduction (sideways) motion. You will also have to limit reaching behind your back. A person may typically wear a sling for 2-4 weeks while limiting the motion.

The initial treatment to maintain ROM is to perform the pendulum exercise (as demonstrated in the picture on the left down below). Bend forward at the waist, and let your injured arm hang down toward the ground. Make small circles with your hand, and let the momentum move your arm around effortlessly.  Try to make both clockwise and counterclockwise circles. For more instruction, please watch How to Properly Perform Pendulum Exercises.

Around the 2-4 weeks mark, you can begin to work on regaining full forward flexion by using an over-the-door shoulder pulley (as demonstrated in the picture on the above right). Work slowly on motion for 5-10 minutes at a time. You may push though minor discomfort, but you should never experience significant pain during this process. For more instruction, please watch How to Use Shoulder Pulleys to Regain Shoulder Motion.

As flexion improves (typically after the 4 weeks mark), then you can begin to work on all other motions of the shoulder. This includes motion out to your side (abduction) and behind your back (internal rotation). The shoulder pulley can be utilized to regain these motions as well. Otherwise, you could walk your fingers up the wall when facing forward to regain flexion and sideways to regain abduction. You could use a towel to regain the motion behind your back.

Strengthening

Initially avoid lifting anything over 5 pounds. Typically around the 4-6 weeks mark (depending on severity of injury), you can begin a gentle rotator cuff strengthening program. These exercises should always be performed pain free and initially, the resistance will be very light. For specific exercises, please refer to Rotator Cuff Exercises.

The rotator cuff is a critical component to shoulder mobility. It is made up of four different muscles whose job is to make sure that the ball of the humerus (arm bone) rotates and slides properly in the socket, which is made up of the scapula. The rotator cuff allows the other major muscles of the arm, such as the deltoid and Latissimus dorsi (lats), to properly move the arm.

When there is weakness or dysfunction, it will cause rubbing of the muscle tendon on the bone. This can lead to impingement or eventually fraying and tearing. Insuring proper strength in the rotator cuff after a collarbone injury is an important component in avoiding shoulder impingement syndrome.

Return to Full Activity

Around the 8-12 weeks mark, you will likely consult with your physician to have another X-ray taken.  Once you’re cleared by your physician, you can slowly taper back into more strenuous exercises and a return to full activity.

If your injury was severe or required surgery, it may be closer to the 16 weeks mark before you can return to full activity and be cleared to lift heavier weights.  I recommend that you slowly taper back into your prior activities.  If you are experiencing pain, then back off that particular activity and try it again at a later date.

Help from a Physical Therapist (PT)

Every injury is different. If you’re experiencing pain or difficulty regaining your strength and shoulder range of motion, please consult with a physical therapist that is an orthopaedic certified specialist (OCS). The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

Good luck, Shawn! I hope you find this information to be helpful and provide some relief from the pain you’re experiencing.

Have you broken your collarbone? What was your experience like?  Please share your best tips for recovery.

If you have a question that you would like featured in an upcoming blog post, please email contact@thephysicaltherapyadvisor.com. For additional health and lifestyle information, join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

How rehabilitation progresses will vary greatly for each individual.  Therefore, no treatment plan will be alike.  For discussion purposes, I will address a generic treatment plan, which should be modified for your personal needs and activity level.  In this final stage of rehabilitation, you will progress to normal daily activities, including any athletic endeavors.  This is also when you work toward limiting any future re-occurrence of the sprain.

At this stage in recovering from a lateral ankle sprain, you should be walking relatively normally and mostly pain-free.  Running and more active side-to-side movements likely still cause pain.  Although not contra-indicated, these types of activities should be limited (unless you’re wearing a good lace up brace or are being regularly taped by a professional).

The initial portion of the rehabilitation is centered on improving ankle and foot strength, stability, as well as addressing any balance deficits.  This process begins with statically based exercises and activities.  Ultimately, it progresses into dynamic strength, balance, and mobility activities.  How rapidly a person progresses in this phase is wildly variable.  The key is to progress at your own pace.  If you start experiencing increasing pain, feelings of ankle instability, and sensations that it may “roll” or sprain again, then you need to taper down your activity level.  After the pain subsides, continue to focus on the activities that that didn’t cause pain or discomfort previously.

The following treatment plan includes exercises for strength and balance as well as mobility drills and full athletic simulation drills.  Each category is listed in an easiest to most challenging format.  You shouldn’t progress to the next exercise until the first one is mastered.

Strength

• Continue with the Ankle Resistance Exercises, but progress to a stiffer Thera-Band Exercise Band (http://amzn.to/USkOeo).
• Heel/Toe Raises – A person should be able to perform 25 heel raises in a row with only minimal fingertip assistance on a counter top. A normal amount of calf strength would be considered once you can perform 25 heel raises. 

• One Leg Squat – Perform a one leg squat without using your hands for balance to increase the difficulty level. The one leg squat on your tip toes is a harder variation which involves more calf muscle activation. Start with two sets of 10 repetitions, then progress to three sets of 10 repetitions.

• Clock Exercise – Stand on your affected (injured) foot and attempt to touch your tip toe of the non-affected side as far out as you can reach. Bring your foot back to the center or starting point according to the hands on a clock. For example, 1 o’clock to 6 o’clock (clock-wise) or 12 ‘o clock to 6 o’ clock (counter clock-wise) depending on which foot is affected. Perform the routine between three to five times slowly.

Balance

• Stand on one foot – A 30 second hold with eyes open during the first time, then closed during the second time, is considered normal.
• Stand on one foot on a pillow – A 30 second hold for two to three repetitions. As you progress, stand on the pillow and perform the Clock Exercise as described above.
• Stand on one foot on a water noodle – This exercise challenges your balance due to the softer surface and narrow water noodle. It also challenges the side-to-side stability of the ankle, which is the weakest area, yet the most critical, with a lateral ankle sprain. A 30 second hold for two to three repetitions.

• Stand on one foot and bounce a ball against a wall.
• Stand on a Wobble Board, Bosu Balance Trainer, or other unstable surface.

Mobility Drills

• Initially, start with forward and backward movements and progress from a walk, to a jog, to a sprint.
• Jump Rope
• Side Stepping – Progress the speed as pain allows and if you’re not experiencing the feeling of instability.
• Karaoke or Grapevine – Walk or run sideways while alternating the placement of the foot either in front or behind the other.
• Sprint Ladder – A number of agility drills can be performed with the sprint ladder. Search YouTube and pick your favorite video which closely mimics the footwork desired for your particular sport or activity.
• Short side-to-side Wind Sprints – While sprinting, touch your hand to the ground at each change of direction.

Full Athletic Simulation Drills

• Depending on your sport of choice, return to your sport specific training drills. You may still require additional support. I recommend wearing a good lace up brace or being taped by a professional for support. Additional support should only be used temporarily and with the intention of progressing from using them as your ankle can tolerate.

Depending on your time table for recovery and the severity of your injury, the information provided in this three part series on ankle sprains will likely be very helpful in your recovery.  For some, it won’t fully meet your needs for a full and speedy recovery.  Each person and injury is different.  If you continue to experience pain and swelling, and/or require an accelerated time table for recovery (or return to competition), then I recommend the services of a sports medicine physical therapist or athletic trainer.  Many modalities, such as electrical stimulation, manual techniques and taping methods can assist in recovery when properly utilized.  To find a qualified physical therapist in your area, search at American Physical Therapy Association (APTA).

If you have additional questions or comments regarding this series, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

Sprains are categorized as Grade I, II, or III.  A Grade I sprain is the most common.  It’s typically associated with only mild damage to the ligament, and instability doesn’t affect the joint.  A Grade II sprain is a partial tear to the ligament and is usually associated with some laxity (hypermobility).  If this occurs, it’s best to wear a brace for several weeks.  Ideally, scar tissue will form and compensate for the lax ligament, so the joint doesn’t become hypermobile.  Good muscle strength and proprioception of the lower foot is important to limit future sprains.  In Grade III sprains, a full tear of the ligament occurred.  One typically consults with an orthopaedic surgeon for possible repair.  After surgery, a guided physical therapy program is recommended.

For discussion purposes, I will only address a Grade I sprain.  Initially, one may wear an air splint, ACE wrap, or some other lace-up or slip-on style brace to help with stability, inflammation, and pain control of the ankle.  In most cases, a person will want to transition from wearing the brace as soon as the initial pain subsides.  (If one had a Grade II sprain, he/she would wear a splint for several weeks so that the ankle would initially stiffen.)

At this point in your recovery, you are likely three to seven days since the initial injury.  This phase of rehabilitation can last from seven days to several weeks before progressing into the final phase of rehabilitation (and ultimately, back to full function).  Progression out of the intermediate phase is always symptom dependent.  You should be able to stand with equal weight on your feet and not experience an increase in ankle pain.  The ankle is likely stiff at this time, but it is time to start walking, progress range of motion (ROM), and start gentle resistive exercises.

• Walking – If you have been using a crutch to unweight the foot, then start the progression to weight bearing during walking. If you have been walking, then increase the amount of weight you have been putting on the ankle and foot. At this time, the focus will be to normalize your walking pattern. This means having a good heel strike, rolling onto the foot into full weight bearing on the leg, and then propelling forward with a good toe off. You will continue to use the crutch as long as needed until you can walk nearly normal without limping. Until then, utilize the crutch to unweight the leg and foot as much as necessary to perform a nearly normal walk or gait sequence.
• Range of Motion (ROM) – Start to increase the range of motion of the ankle. Initially, work to progress the plantarflexion and dorsiflexion movement (the forward and backward movement of the ankle). As pain subsides, progress the side to side motion as well as all other motions.
• Recommended Exercises:
  • Ankle Pumps – A very easy exercise. Just pump your ankle forward and backward into plantarflexion and dorsiflexion movement. Perform 10-15 repetitions several times a day on both feet

•  Ankle Alphabet – Move the foot and ankle only by pretending your big toe is a pen, and draw the alphabet using capital letters.  Perform 1-2 times a day.
• Calf Stretching – Hold each stretch for at least 30 seconds, three times on each leg, 2-3 times a day. This stretch shouldn’t cause more than a mild increase in pain or discomfort.

• Gentle Resistive Exercises:
  • Perform plantarflexion and dorsiflexion movement by initially using an exercise band. I recommend using a Thera-Band Exercise Band (http://amzn.to/USkOeo). As your pain improves, you can progress to standing heel and toe raises as long as you don’t experience more than a mild increase in pain levels.
  • As pain and range of motion improve, progress to inversion and eversion with the exercise band. Stop if you experience more than a mild increase in pain levels.
  • For further instruction and photos, please refer to Ankle Resistance Exercises.
• Initial Balance and Proprioception Exercises. For a complete discussion on the specifics of balance, please refer to How Do I Improve Balance? (Part I) and How Do I Improve Balance? Part II.
  • Standing on one foot. Initially, you may need to use your hand (or a finger) on a counter top for added support. As the pain subsides and your balance improves, you may need to increase the difficulty level. As you progress, balance will become of greater importance (to be addressed in Part III).

Toward the end of the intermediate phase, you should be walking fairly normally.  There will likely be some swelling.  It is typical for some amount of swelling to come and go.  It will be directly related to how long you are on your feet and your general lower extremity circulation.  I highly recommend you continue to wear compression stockings during this time.  You may also continue to experience soreness and pain–particularly after a long day or a lot of upright activity.  Continue to utilize a regular icing protocol as needed for pain and swelling.  Also, continue to supplement with Capra Flex by Mt. Capra (http://amzn.to/1pF936I).

It’s time to progress into the final stage of rehabilitation once you have returned to near normal walking, your pain levels are relatively low, and you are able to complete the basic exercises listed above.  The final stage of rehabilitation includes a full return to daily activities and eventually, all sport or athletic activities.  I will address the specifics of the final stage of rehabilitation in Part III.

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Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

A.  Thanks for your question, Linda!  Unfortunately, this is a fairly common scenario.  Shoulder pain can be one of worst most intense pains a person can experience.  It can be completely debilitating–rendering an arm almost useless in some cases.  The shoulder is vital for any movement of the arm which includes the hand.  It can even affect a person’s ability to utilize a computer mouse.

Linda doesn’t mention any specific causative factor which is common in these cases.  She also mentions pain at night and pain with movement.  Another very common symptom is where she describes the stabbing pain in the deltoid.  The pain is almost always located down the arm into the deltoid area.  Typically, it is located at the insertion point of the deltoid muscle.  It can migrate even further to the elbow or hand.

In a situation like Linda’s, the source of the pain is rarely the deltoid and almost always the rotator cuff.  The rotator cuff tends to “refer pain” into this region.  Referred pain is a common phenomenon which occurs when the pain is being caused in one area of the body, but the pain is felt somewhere else.  (An example of referred pain would be left arm pain or jaw pain which is present during a heart attack.)

Linda states that the pain is present when she raises her arm.  This implies that she still has the ability to raise her arm, which tends to (but not always) rule out a full rotator cuff tear.  Typically with a full tear, the person loses the ability to raise his/her arm.  The level of pain on a full tear will vary depending on how acute or recent the tear.

To accurately diagnose Linda’s condition, I encourage her to seek treatment from her medical physician or physical therapist.  Based on her reported symptoms, she is likely experiencing either a partial rotator cuff tear or shoulder impingement.  Shoulder impingement can lead to an actual rotator cuff tear if it remains untreated.  The key to treatment (with either a partial rotator cuff tear or an impingement) is to first address the pain and inflammation.  Then the mechanical cause or causes which led to the injury must be addressed.

My Top Tips & Recommendations to Treat Shoulder Pain & Impingement include:

Reduce the Inflammation:

• Use ice on the affected area (not directly on the skin) for 20 minutes per hour. Watch the skin carefully. If it looks white or blue and is non-blanching, then discontinue the use of ice. It is possible to frost bite your skin.
• Rest the affected area. Stop or reduce any activities which tend to aggravate the area. This is typically overhead activities or repetitive activities.
• When sleeping, try not to lie on the affected side. Hug a small pillow for comfort. This also promotes optimal blood flow to the shoulder area.
• Try Mt. Capra CapraFlex. Mt. Capra, an organic goat farm in eastern Washington State, offers superior quality products primarily utilizing goat based products. Capra Flex is the best bone and joint supplement I have found. It is a blend of natural herbs and spices along with glucosamine and chondroitin. The herbal and spice formulation is designed to naturally decrease inflammation and support healing. I recommend it to anyone recovering from an injury or attempting to prevent injury when performing at a very high level. I personally use it, and in my practice, it has helped clients recover faster and prevent injury. It can interfere with some blood thinning medication, so if you are on this type of medication, please check with your physician.

Address the Mechanical Causes:

• A slouched posture with a forward head and rounded shoulders can be associated with this condition. Try to keep a good postural alignment with your shoulders under your ears and the shoulder blades set in a back and down position. This is particularly important when performing any activity while using the shoulder.
• Improve thoracic (upper back) mobility. The more mobility your upper back has, the less likely your shoulder will impinge when moving. Your upper back, shoulder blade, and arm must work together when moving. Tightness in the upper back will throw this system off.
• Be sure to check out My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain.  By subscribing to my e-mail list, you will automatically gain access to this FREE resource.  Download the .pdf file, which is full of photos and exercise instructions, to get started!

Strengthen the Rotator Cuff:

• The rotator cuff is a critical component to shoulder mobility. It is made up of four different muscles whose job is to make sure that the ball of the humerus (arm bone) rotates and slides properly in the socket, which is made up of the scapula. The rotator cuff allows the other major muscles of the arm, such as the deltoid and Latissimus dorsi (lats), to properly perform. When there is weakness or dysfunction, it will cause rubbing of the muscle tendon on the bone–leading to impingement or eventually fraying and tearing.
• Here are my recommended Rotator Cuff Exercises  using an exercise band.

Shoulder impingement or a partial rotator cuff tear can be very painful and may take many weeks to recover.  My tips and recommendations are the first steps for treating and preventing shoulder impingement and pain.  Many different causative factors can lead to these conditions.  In most cases, shoulder impingement (or even small partial tears) can be completely rehabilitated and should (when treated properly) leave no residual effects once a person has recovered.

If your symptoms continue to worsen or you don’t improve, I highly recommend that you seek further medical treatment.  Many times, a person will require medical intervention, which could include anti-inflammatory medications either orally or through an injection.  A person may also need hands-on treatment from a qualified physical therapist to address other mobility issues in the shoulder, thoracic or cervical regions which are causing or contributing to the pain.  Sometimes, surgical intervention is needed to repair a fraying tendon or an acromion which is hooked and causing the impingement.

Good luck, Linda!  I hope you find the information to be helpful and provide some relief from the pain you’re experiencing.  If you have a question that you would like featured in an upcoming blog post, please e-mail contact@thephysicaltherapyadvisor.com.

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.