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Welcome to The Dr. JJ Thomas Podcast! Here I'll be talking all things physical therapy, raw and unplugged, giving you the unfiltered insights you've been searching for in your cash-based physical therapy business. If you're caught in the grind of the traditional model, swamped with paperwork, or feeling like you're not reaching your full potential as a physical therapist, this podcast was created just for you.
So by shortening her abdominal muscles, her shoulder moved better. So this is something we teach the ins and outs of in our primal university courses, especially our primal foundations course. And you would get a lot of in our mentorship program. But learning how to, you know, to get patients to that extra extra percent better, you know, that extra top 1% is to treat the whole body as a system and to look for these relationships. Welcome to the doctor JJ Thomas podcast.
Dr. JJ Thomas:Hey, everybody. Welcome to the doctor JJ Thomas podcast. I'm JJ Thomas. I have Shannon here today with me. Today we're gonna dive into shoulder impingement and how to better evaluate your patients with shoulder impingement, in a way that gets you to sort of the diagnostic approach of where to treat first, faster.
Dr. JJ Thomas:So I'm gonna show you some of the little tips and secrets that I've seen along the way with evaluating motion just a little bit more deliberately in certain phases that can help hopefully direct your clinical patterning so over time you know where to go faster and you can make the most out of your time and their time and just like I said, get them better faster. So here we are. So Shannon is 1 of our 1 of our staff here at Primal PT. She's we call her Disney Underground. She she and David keep keep us keep us running on a lot a lot of levels.
Dr. JJ Thomas:But she's here today, we're gonna go through some motion patterns and, actually, I'm gonna have you stand up first. Still in frame. Good. And just stand facing this way, actually. And let's actually square you off this way.
Dr. JJ Thomas:Good. I'm gonna pull your hair behind your head, like that. Okay. So the first thing I wanna teach you guys is, when testing shoulder patterns, so a lot of times what I'll do is a gross motor pattern first, and I want you to get in the habit of looking at where the pattern seems to be limited during each phase of the motion. And this is what I mean by this.
Dr. JJ Thomas:So Shannon, I'm gonna have you just take that right arm and go straight up into flexion as far as you can, and good, and come back down. And almost everybody wants to please us, every patient, every athlete, every co worker. So a lot of times they'll bend their elbows. So we have to if we're gonna really tease out the motion, you have to make them be really deliberate with keeping that elbow straight. So let's do it again, Chen.
Dr. JJ Thomas:Keep that elbow really straight and go back there, that's good. Now go back as far as you can with your arms straight. See how that's restricted for her. I'm going to come on this side so I can show you. And let me just tuck that in.
Dr. JJ Thomas:At that end range, I'm starting to look at already come back down, let's do it 1 more time. Let's go ahead and take that off. She has a bruise. She got a she got she got a little bruise from from some treatment last, earlier, just a few days ago. But, so elbow straight, go straight up as far as you can.
Dr. JJ Thomas:Awesome. Try to push it back as far as you can. So you can see she has to work, that's efforted. Right? So that is not a clean, pure motion.
Dr. JJ Thomas:I'm already looking at where does that seem like it's tying up. If you look, you can see these fibers here sort of straining at that, this this front pack. And, Jess treated her here, Jess did a good job. I think Jess saw what I'm seeing here because left a bruise in a spot that I would have treated. So, yeah, that's limited there.
Dr. JJ Thomas:And a lot of times we're looking at what's happening at the shoulder blade. A lot of times Shannon isn't so bad here, but in a you can go ahead and put it down. Am I still in the frame here? A lot of times what you'll see is that shoulder blade, when they come back, will like pop out a lot. And then then I'm gonna evaluate, I'm gonna look more closely at this like lat teres major, teres minor area when that's limited.
Dr. JJ Thomas:Now the other piece of this that we're gonna look at, go ahead up into the end range again with your elbows straight. Elbows straight and then go straight up, back as far as you can. From here I want you to take this hand and touch over to the opposite shoulder, so over here. Good. Now, for Shannon that didn't change.
Dr. JJ Thomas:For some people when they go to do this and they go to touch behind, their arm comes forward. They struggle with that. You can put it down. What that tells me is that their tricep is involved. Right?
Dr. JJ Thomas:Because if you're here and then all of a sudden you can't maintain that shoulder flexion as you go to just bend the elbow, then the only thing that it that is changed when we're bending the elbow there is the tricep. And that long head of the tricep attachment, attaches into the scapula. So when they do this, if it's more efforted, then I know that that long head of the tricep is affecting their shoulder. So that's a little secret there I wanted to share with you. Let's look at the flexion internal rotation pattern.
Dr. JJ Thomas:I'm sorry, extension internal rotation pattern. So now you're gonna go back like this, Shannon. Elbows straight, go back as far as you can, keep your chest up. And I'm gonna come on the other side, and that looks pretty good for her. So come on back down.
Dr. JJ Thomas:A lot of people, when you're looking at that, what you'll see is, even if I say, bring your elbows elbows straight, bring your arms straight back as far as you can, they'll dip like this. And then I'm going right back to that pec region again. For Shannon it wasn't too bad. So now I'm combining my findings. When she went up it looked tight in that pec region, but more in that, like, anterior delt pec region.
Dr. JJ Thomas:When she went back her pec didn't pull her forward. So I'm definitely thinking more anterior delt here for her. So just paying attention to what's happening at the rest of their body when you're giving them the cues and ask them to do that extension pattern. So now Shannon, go straight back into extension, her pec does a nice job of staying erect there, from there can you touch behind the opposite shoulder blade? And now that's where she comes forward more.
Dr. JJ Thomas:So, let's come out of it, turn that way just a little, good, go straight back again, and then from there touch behind. So you see how when she goes to internally rotate, she gets a lot of forward pull there. So now that brings my brain more, come on out of it, to this, to this posterior cuff. So infraspinatus, maybe supraspinatus, but definitely infraspinatus, and teres minor at teres major, sometimes teres minor in lats as well. You have to tease that out prone, which is what we're gonna do in a minute.
Dr. JJ Thomas:But the other thing I wanna teach you guys real quick is a regional interdependence thing that you should check, and that's go ahead and have a seat on the table, Shan And that's checking shoulder flexion, shoulder patterns, specifically shoulder flexion, and external rotation in sitting versus standing. And so Shannon, from that position, go up as far as you can. That's easier, isn't it? So she actually has better range there. So what does that tell us?
Dr. JJ Thomas:What did we change? The only thing we changed here was her hip and abdominal position, right? So that actually tells me that her potentially tight hip flexors and abdominal tightness are affecting her shoulder. So pulling so these muscles are pulling all the way on her ribs up to the pecs and and manifesting as tightness in the shoulder. So let's just highlight that again.
Dr. JJ Thomas:So stand up, and then yeah. That's good. From there, raise straight up overhead, elbow straight. You can see it pulling at that end range. Right?
Dr. JJ Thomas:Let's give them a side view of that, so face that way. So elbow straight, go straight up, back as far as you can. Right there. You see how right there it's like zoom, the whole shoulder blade goes, and you can see she just can't get there as far. Let's sit this way, Shan, so they can see better.
Dr. JJ Thomas:And then do the same thing in this position, elbows straight, go straight up. Easier. See how she goes? Her range is further, and she gets there better. So by shortening her abdominal muscles, her shoulder moves better.
Dr. JJ Thomas:So this is something we teach the ins and outs of in our primal university courses, especially our primal foundations course. And you would get a lot of in our mentorship program. But learning how to, you know, to get patients to that extra extra percent better, you know, that extra top 1%, is to treat the whole body as a system and to look for these relationships. Now, in some people their shoulder flexion range might be worse when they're sitting. And what would that tell you?
Dr. JJ Thomas:It would tell you that her low back tightness, or specifically her posterior chain, in some way, shape, or form, could be her glutes, are are limiting her ability because we're putting stress, we're putting stretch on the posterior chain. So if her shoulder flexion gets less there, then I know that I'm gonna loosen her, probably her low back and posterior chain, but I would tease it out specifically. And And that's what we teach you how to do in detail in our courses. Let's do 1 more piece of this evaluation. So now, Shannon, I'm gonna put that back up.
Dr. JJ Thomas:You're gonna go face down. Yep. Thank you. Good. And then, you know, this is something I originally learned through SFMA, and I'm not honestly sure at this point if I learned the sort of every component looking at every component through them or not, but I'm gonna show you it anyway because it's very very valuable.
Dr. JJ Thomas:So elbow straight here and lift straight up. And so she still wants to bend that elbow because she wants to there she goes. And I know that I can bring her further than, than she can bring herself. So that's a motor control deficit. But again, my point to you is we wanna look at where we see her limitations.
Dr. JJ Thomas:So do it again, Shan. Yep. Lift up. And then when I bring her up, I mean, all I see is this gap in this position is really riding out this way, and so when I go to treat her, I'm gonna definitely, work a lot in this infraspinatus, in this, the triangular interval is made up of teres major and the 2 heads of the of the tricep, the long head and the lateral head. And so all of those and teres minor in here are a real great spot for these people with shoulder impingement.
Dr. JJ Thomas:And when you loosen all this stuff up, then their end range flexion gets better. And their all their motion gets better. External, internal, all the motion. The other thing that you can look at is if they have a motor control deficit, go ahead up again, Shan, look at, again, how they're pulling here, so lats are often a factor, and low trap. So low trap will also be a big player, and if I feel Shannon's, I can see that it's really tight there.
Dr. JJ Thomas:So that's something I would normally needle on someone like Shannon. And then, but for Shannon specifically, go ahead and sit up. I actually didn't expect to be teaching you guys this, but it's so much fun when we do these live, kind of live scenarios. So for Shannon, I would definitely, number 1, massage and or needle her abdominals. I would evaluate her anterior chain, meaning her hip flexors, because when we shortened them her shoulder flexion got better.
Dr. JJ Thomas:Including the adductors because the adductors are hip flexors as well, most of them. And then I would go to the I would retest right after that so that I could see how that changed her shoulder immediately. I already know it's going to change her shoulder because her shoulder range of motion and flexion is better in sitting than standing. And then, I would tease out the shoulder further. And I would probably end up addressing, if it was still present, the anterior delt tightness that we picked up on shoulder flexion, and the posterior cuff tightness, in the infraspinatus, teres minor major, and long head.
Dr. JJ Thomas:Actually, for her triceps wasn't involved because when she bent her elbow it was, the same. So that's how I would treat her in terms of interventions. I also wanna go through some exercises with you guys right now. My 5 favorite exercises to give to our patients with, impingement, issues in the shoulder. Remember that ideally you're going to give them exercises that are very specific to their deficit.
Dr. JJ Thomas:Right? So for Shannon, we're going to make sure that we're also addressing her anterior chain deficits in her abdominals and her hip flexors, and you can combine that with exercises. We'll go through it in a little bit. Hey, guys. Welcome to the mat.
Dr. JJ Thomas:I'm gonna go through some of my 5 really 5 of my favorite exercises to give our patients with shoulder impingement. And I love them just because they're very integrative. As we talked about treating the body as a system, if you're really gonna treat and train the body as a system, you need to incorporate the shoulder exercises you're doing with your patients, we need to do that, in other positions that will also incorporate the rest of the kinetic chain. So Shannon, thank you for being here. I'm going to show 1 of my first favorites, very basic.
Dr. JJ Thomas:I'm sure you guys already give this 1, but I want to point out a couple of details with them. Shannon, you're going to start in, like, a high plank position. Let's do a side view, actually. Great. Great.
Dr. JJ Thomas:So, yep, Shannon's doing a great job because she's, she's here and and knows how we our standards for things. Shoulders are stacked over wrists, head is in neutral, so not letting the head hang, but the ears in line with the shoulders. Belly lifted, tail tucked. That's perfect. Now, I'm locking the lumbar spine here, and now I'm going to ask Shannon to let your shoulder blades fall together without letting this fall.
Dr. JJ Thomas:Great. And then push the floor away farther than you think you can, get that thoracic round. Now this is really a serratus punch. Right? A closed chain serratus punch.
Dr. JJ Thomas:And we're also on the way down, go ahead down again, getting scapulothoracic mobility, which she needs, which is going to stretch that rotator cuff on the outside as she comes down. Come on back up. Now, Shannon, on this 1, let your back sag, which I would normally not let you do. So come down. Yeah.
Dr. JJ Thomas:So that's not going to get the scapulothoracic mobility we need. It's gonna have people hyper sort of just, compensate through their low back. Again, we're almost done, Sean. Just to keep this nice and high, tuck the tail. Great.
Dr. JJ Thomas:Let's do 1 more rep. Let it sag in only the shoulder blades, and drive away further than you think you can. Get that round here. Push, push, push, push, push. Yes.
Dr. JJ Thomas:And that's it. So that take a break. That was great. So those are the cues. Yeah.
Dr. JJ Thomas:Intention is everything. Right? Those small details mean everything. So making sure that the lumbar spine is locked, making sure that the tail is tucked, making sure Shannon also automatically did fingers spread and elbows straight, which all of our patients will not do immediately, but, but that's another thing. Because if they're in this position, I'm just gonna go next to you, and they're doing this, meaning elbows are bent, they're using they're using they're they're using their bison tries more than they're using, cuff, exactly.
Dr. JJ Thomas:So when they come down here, they're going to get that cuff stretch if they're holding all those things with intention. So now that's my first favorite exercise, and that's basic. Almost everyone gets that day 1 because if they don't have that scapulothoracic control, their cuff is gonna compensate again and again and again and again. My second favorite exercise for them, and these aren't necessarily in order, but these are my first top 2, is the, oblique plank reach reach throughs. So Shannon, I'm gonna have you we'll go this way now so they can see.
Dr. JJ Thomas:So plank in this position. Same, standards, fingers spread, elbows straight, shoulders stacked over wrists. This time, I'm gonna have you take 1 arm and reach through the other 1. Yep. Good.
Dr. JJ Thomas:Come out of it. Let's widen your feet a little bit more so that you have a little bit a little bit more even yeah. And then reach through again. So as she's reaching with her left, come back down, and other side, as she's reaching with her left, touch the ground the whole time. Uh-huh.
Dr. JJ Thomas:And then come back. As she's reaching with her left, her right cuff is controlling that eccentrically. Reach with the left, keep the arm in contact the whole time, and you can see how that's harder for her. That side, reach with the right, reach reach reach. Excellent.
Dr. JJ Thomas:Reach with the left. Go slow, only go as far as you can go. Controlled. Yes. She has a hard time controlling her hips on that 1.
Dr. JJ Thomas:Now, come on out of it. The reason this is this is a great exercise for everyone is that, as I said, eccentrically, as they reach so for Shannon, it's her right cuff. As she reaches here, her cuff is controlling that horizontal that relative horizontal adduction. She's getting eccentric cuff activation of those external rotators. It's beautiful.
Dr. JJ Thomas:Plus, she's getting abdominal activation at the same time and learning to control her hips under her under her pelvis and under her spine at the same time. So it's a great, great exercise for a 1000000000 reasons. The next 1 you're gonna do is another 1 of my favorites. We're gonna do backwards bear. I'm gonna teach her forward bear first, and then she knows it because she works here.
Dr. JJ Thomas:But, and then we're gonna do backwards bear because backwards bear is really the the most important 1 for these cuff patients, these impingement syndrome patients, and I'll tell you why. So, Shan, come on sideways again, head facing that way. Good. And, fingers spread, elbows straight, tuck your toes, and come up into that a frame. This is a GMB Fitness special.
Dr. JJ Thomas:Good. Now, in this position, Shannon looks great. Holy crap, that looks so good. Let's walk your hands away a little further. A little bit, like, keep them a little further, and that's just for you guys listening.
Dr. JJ Thomas:I'm doing that because I want the weight on her shoulders. I want scapular stability, I want shoulder stability. Walk a little further even. Good. Now relax the heels.
Dr. JJ Thomas:Awesome. That's a great start position. Now, Shannon, opposite arm and leg slide together, I want you to move opposite arm and leg just a few inches. Great. And then the other 1, just a few inches.
Dr. JJ Thomas:And then the other 1, just a few inches. Uh-huh. And then the other 1. Good. Now go backwards.
Dr. JJ Thomas:Drive with the base arm. That's it. Opposite arm and leg still slides together. Perfect. So imagine she's getting a single arm press here through this backwards bear.
Dr. JJ Thomas:Come on out of it. It's hard way harder than it looks. Shannon made it look easy. So a couple of cues there, a couple of tips to remember, most patients are used to the yoga concepts of, and and we're ingrained that we need flexibility, we need flexibility. And a lot of patients will immediately go into, like, a downward dog where they're, like, here and they're trying to get their heels flat.
Dr. JJ Thomas:See how here, first of all, my head peeks out from my shoulders there, and there's less weight on my hands and my feet here. I want the weight on my hands because I want that shoulder stability. So even though Shannon's a frame looked amazing, I had her walk her arms away, so that she would get more weight on her arms than her feet. And then, forward, opposite arm and leg slides together. Most people will accidentally bend, And then all of a sudden we're missing that frame.
Dr. JJ Thomas:We're missing that shoulder frame to get scapular stability. And then backwards, this is where So if you go opposite arm and leg slides together, see how this trail arm drives away. Boom. And it's in relative overhead position. So most people in that impingement process are getting impinged because their scapular control at shoulder flexion ranges is poor.
Dr. JJ Thomas:So all of a sudden now you put them in their end range shoulder flexion, and you ask them to drive the floor away, engaging serratus anterior and all the other scapular stabilizers, and they have a win. Not only that, but now their core is engaged at the same time, so we're treating and training the body as a system. Now for Shannon specifically, I wanna add a variation because of her hip flexor tightness. So come back into that position for me, and I would give her backwards bear because it's amazing, but I would also say, come forward just a little bit so you're in the frame. Great.
Dr. JJ Thomas:So right there, I would have her in that position. Now, I would have you, so it's her right shoulder, so I'm gonna have you raise opposite leg. Yep. And raise it high, like, super high. Good.
Dr. JJ Thomas:And then from there, I want you to press the floor away. Like, that's it. And then come back. Good. So press away.
Dr. JJ Thomas:So we're getting scapular we're basically getting scapular protraction in shoulder elevation while she's maintaining this leg in a hip extended position. So now I'm integrating those hip flexors that we're limiting her in standing over there. Pretty cool. Right? Come on out of it.
Dr. JJ Thomas:So that was just something I created on the fly for Shannon, because when we evaluated her, her hip flexors and abdominals were clearly limiting her shoulder flexion capacity. So we can put her weight bearing, engage the shoulder flexion, stabilize the stabilizers we need in shoulder flexion, and then integrate that hip to get it extended when the body feels safe because it's in that loaded position. So thank you. Mhmm. 2 more quick exercises.
Dr. JJ Thomas:This one's gonna involve dumbbells. So basically, you can stand, Shan. Can have them do the stand actually, we'll do it standing. So you're gonna stand in front of the camera, and you're gonna I'll stand next to you, stand facing that way. Yeah.
Dr. JJ Thomas:And then you're just gonna start with your arms at 90 90. Good. We good here, Dane. And then you're gonna fly out your arms like this. Uh-huh.
Dr. JJ Thomas:When she does this, I wanna make sure that this isn't already falling, so she did a nice job of keeping it in line with her elbows. And then I want you to rotate it up. Now soft bend in the knees, I want you to hold that rotation as you bow forward like a good morning. Uh-huh. Eyes forward.
Dr. JJ Thomas:Eyes forward. Yes. A little bit more. Look at the camera, actually. It makes it hard.
Dr. JJ Thomas:And then come up. Yes. Well, it makes it but it also engages your spinal erectors. So by having her make sure she's looking forward rather than down, yeah, you can take a break. She's maintaining her she's engaging her spinal erectors, which we know she needs also for scapular engagement.
Dr. JJ Thomas:So 1 more time. So fly it up, rotate it up, soft bend in the knees, eyes stay forward, and good morning, down. Awesome. And then come back up in that position, and then reverse it all. So now fly, yep, and fly, and then down.
Dr. JJ Thomas:So what she's doing is an isomet she's doing an active rotator cuff exercise with the dumbbells, but then she's maintaining it as she's integrating a bow into a good morning exercise and teaching her shoulders to stabilize as gravity changes the demands on her spinal erectors and the rest of her body as it relates to her hips. So not a good 1. Yay. Fun. Right?
Dr. JJ Thomas:And then the last 1, we can put the weights away. The last 1 is a very I ended with this 1 because, it's truly a stretch. Like, this next exercise is a traditional stretch. Any of you that follow me regularly know that, you know, I do give stretches, but for the most part, I also believe that most mobility issues will improve if you give the body the stability it needs that it the stability that it needs. And so this stretch sometimes you do need to do stretches to be able to perform the stability exercises, but, but not always.
Dr. JJ Thomas:Sometimes if you just do those first 4, then the mobility itself will improve. But let's show it anyway. So Shannon, for this 1, you're gonna lie on your right side, it's her right shoulder, face the camera. Yep. I'm gonna grab a pillow, just Yep.
Dr. JJ Thomas:For your head. And then, right. You're gonna have so actually, this arm, I'm actually gonna have you so 90 degrees, can you see us? 90 degrees, I want you to pull the shoulder blade back as far as you can get it. Pull it, pull it, pull it, pull it.
Dr. JJ Thomas:Yes. A little bit more. Yes. So I actually pulled her shoulder blade back, and then bend your elbow. She's really close to 90 degrees.
Dr. JJ Thomas:She came down a little bit, so bring that elbow up a little bit towards your face. Yep. And then keep this here, take this hand, put it under the elbow, and then lift this up towards the ceiling. That's great. Feel that stretch in the back of your shoulder here, and then I usually relax your head, but keep this up.
Dr. JJ Thomas:I usually I don't have patients count, I have them breathe. So 5 long deep breaths here, and that's gonna, then I know she's getting rib expansion to get the most out of the exercise, and it's a way of counting without being like, 1, 2, 3, 4, 5. So it's 5 long deep breaths, and that's the exercise. The things that will go wrong there, as you you guys probably use this 1, the therapists that are watching, I'm sure use this 1. Some of you use the sleeper.
Dr. JJ Thomas:The thing I don't love about the sleeper is most people end up pulling their shoulder blade out, and then you're really you're not getting that corner that gets so tight here. But when you do this 1 right, you lock them back, and then you pull, then you're getting you're getting that component here that's so tight in the cuff. So this is my go to over the sleeper stretch. If you're not using it already, give it a try. See if you like it better or the same as the sleeper stretch.
Dr. JJ Thomas:I'd love to hear from you. Those are them. Those are the 5. These are the exercises that I consistently give to my patients with shoulder impingement syndrome, pain at night, limitation in in those end ranges of either, you know, flexion patterns or extension patterns. So that's it.
Dr. JJ Thomas:I hope you learned something. I hope you enjoyed it. Thank you so much, Shannon, for donating your time and body. And, let me know if you guys have questions. Love hearing from you.