Is Shoulder Pain Ruining Your Life? SLAP Tears Demystified: Week in Review 40

In this episode, Dr. Beau and Seth discuss various case studies focusing on shoulder pain, diagnosis, and treatment approaches. They explore the complexities of managing patient expectations, functional goals, and the importance of understanding the underlying issues contributing to shoulder injuries. The conversation emphasizes the need for a comprehensive approach to rehabilitation, considering both physical and psychological aspects of patient care.

Transcript

Dr. Beau (00:01.038)

All right, we're back with, I think we said Week in Review, episode 40 last time. We had a great conversation. You'll never know what it was about because the microphones were not selected as the correct input. They were on. We had a great time. It was probably the best podcast we've ever done. I don't know. Actually, it wasn't. It wasn't. Yeah, there's no way to solve it. So I'm just going to, maybe I'll just put it out and put the video out and let all the YouTube comments come in. like, I can't hear anything.

see how crazy it gets. Or just have people put their own audio on. You get actually those little lip readings. That's what we end up The NFL sideline. that's what we do need. That's how we get more views probably. So as you can see, it's just Seth and I today, so everybody else is extremely lazy. know Daniel's oldest son's daycare flooded because pipes froze, then he's kind of dealing with that.

And then I think Alex had to get his perm redone or something. That's typically what happens. That's like a daily. Yeah, it's good. Every other week, then it gets the blue dyed out of it. All right, so today, Seth has a shoulder case. I'm going to kind of just have some filler stuff. And then I actually have an update on some shoulder stuff. we actually talk about that in the last one? Seth's not an update. We'll talk about it a little bit. The person you're going to use is actually like one of the main cases from last time. Yeah.

Yeah, so I'll talk about his case after yours and just kind of draw similarities and stuff. So I'll try and move them my kind of way. All right, you're good. Let's go for it. Sweet. So I've got a 53 year old male that has right anterior superior kind of shoulder pain. Um, he's had this pain like off and on for the last 10 years. There you go. Sorry. He's had it off and on for the last 10 years. Um, but more so felt it, um, Monday, I guess two weeks prior to me seeing him, he was in, he plays in a soccer league.

He's a goalie. So he felt his shoulder when he dove landed kind of felt it right in the front of his shoulder Then the next morning going to work he reached behind him to grab something out the back of the car and when he lifted he felt his shoulder like pop How old is he again? He's 53. It's just side note. I've known this guy for a long time He's like into a lot of varied activities They do like endurance horse rides and then his wife go I went on if they would say climb mountains, but they hike

Dr. Beau (02:24.834)

bigger mountains, like more than just like hiking around here. So a super active guy for a 53 year old. Yeah. That's like at the end of this, like I've gone two weeks without seeing him so far. it's because like this last week he's been down at like his farm doing like horse riding. Yeah. So yeah, he's doing his own thing. Cool. Then let's see. Yeah. So it's happened two weeks ago before seeing me it's progressively gotten worse since he's been in the gym. He goes about three days a week.

Overhead pressing, pull-ups and push-ups are the most painful thing that he does, but he can get through them. He said once his shoulder kind of gets a little warm, it feels a little bit better. And then kind of some pertinent surgeries. He had a labrum surgery to the same shoulder 10 years prior from the same type of fall that he had in soccer. So the exact same thing. Dove to his right, kind of trying to save a ball like above him when he jumped, landed, to his shoulder.

We're saying like landed on he was on a car and it felt top of his shoulder which can be a position you can dislocate a shoulder so that also sets up mechanism injury for maybe overseeing here and then he said he can't really find anything that's like helped it except I think he took

Cerebrex maybe? Celebrex or something. Celebrex, that's it was, yeah. He's like, that's about the only thing that I can get relief from. So top tier, so we're gonna start with just exam, top tier. Dysfunctional unpaingfuls to me that were important was cervical spine extension and right rotation for his neck were dysfunctional unpaingful. Right upper extremity pattern two, so him kind of going above his head.

that was painful and then bilateral multisigmental rotation but more so to the right. That was painful or not? None. Okay. The only thing he had painful was upper extremity pattern one we had to reach behind him, touch his left shoulder blade, broke out the bilateral rotation. He can clear it passively in lumbar lock and then to the right he can clear it

Dr. Beau (04:36.142)

Sorry, dysfunctional, painful, active and passive. So he cannot get there, like joint restriction is just like, mean, it's like a hard block, like he's not going any farther. And then active, goes the exact same range. So exam, shoulder flexion, resisted. I guess that'd be like what, Yerkesons or something like that? Is that what going With your elbow bent, yeah. It's like slightly bent, shoulder flexed, pulling down. That's painful and weak.

Full cam is painful and weak, but nothing with empty cam. So if his thumb turned down, he's fine. But if his thumb's turned up, more pain there. And it's also weak. What's that mean to you? To me... Or do you remember what that means from the orthopedic tests? What the differentiation is? Because you basically...

Superspinatus is going to be on the 45, right, with empty can, but then you do basically a labral shear test, right, with the arm straight out in front or at 90 degrees of flexion, 90 degrees of abduction. So the whole difference is you're going to go palm down, you're going to go palm up, doesn't matter which one you do first. So when you have palm down, you have more of the basically posterior cuff, right, that's coming into play, more same posterior cuff, hyperspinatus, teres minor.

When you flip over, you take some of those out and now you're back on kind of bicep tendon, your gissens. So then you're trying to match. And again, orthopedic tests, I don't know, you know, if it's completely, you know, their shoulders clunking, thudding, it's a two out of five strength. Yeah. But it does tell you, which we'll talk about in this, like it can tell you stuff and then you're like, okay. Yeah. I was on it because multiple pieces of data also the same thing, not just one orthopedic test. Yeah. so yeah, I guess like you're going after more.

The two things that come into play with both of those is like more bicep, like you mentioned, is more involved. then like anterior part of the shoulder, which he said, like, again, it feels the exact same as last time that he had this surgery, or I guess he had the same injury. Neurodynamic testing, recreated nose symptoms, just kind of checking bilateral since he had a restriction for cervical spine. Just checking just my neuro a little bit there. Shoulder flexion painful around 90 degrees to 100 degrees. So if he just like actively goes overhead for shoulder flexion in front of him.

Dr. Beau (06:51.674)

around 90 degrees, he's like, that's where it kind of hurts and catches. And then if he gets through that, he's fine after that. There's like a small little range that he's in. And then immediately as well, when he goes into these, whenever he gets around the part that it's gonna get painful or he expects it to be painful, he's like just super upper trap dominant. And here's a little tip, especially if you're a student or new doc, big conversation here, which sometimes you're like, oh, like I'm way ahead of that. And I don't think a lot of us are.

So lot of times, we'll go through all these tests and you're still like, I don't really know what hell's going on. And then we'll throw out something like, scapular stability or scapular diskinness or something. So let's say somebody has like, I was taught via Winchester advanced biomechanics, like the flexion abduction arc, right? You do abduction, hands apart or palms away flexion. You're looking for reduced range of motion pain, but you're also watching the scapula thoracic or scapula humeral rhythm.

One thing that I've kind of found interesting is, just like if somebody is on a bench doing bench press, your scapula is basically stabilized by the bench. So if somebody has reduced range of motion or pain with just flexing or abducting their arms, you can also have them lay down on your table and repeat the test. If it's wildly different, the likelihood of it being a legit injury goes, in my opinion, not to zero, obviously you can have injuries that you can bypass, but way lower. And then you're looking at maybe the biggest dysfunction and you're like, it's a good little test. Cause what do you do in the flexion abduction test sometimes?

you put your hand on their scapula and you guide it and see like, it improve it? You can lay them down, which is kind of like a, can we make a name up? Like we're to call it the scapula thoracic lock. Boom. That's what we're doing. Great girls. We're coming for you. Yeah. The ST lock. So lay them down on the table, repeat the flexion abduction arc or you know, whatever you want to do flexion and just kind of see. So just a tip if you're like lost. the only reason I went, I say shoulder flexion is because I had him.

when he was sitting up, do the abduction, trying to get back of the hands to touch, and that looked fine. Cause he's like, yeah, I'm good out into the sides of me. He's like, it's only when I'm in the front that I start to feel anything. is another clue, like tick in the box of the same information. So we've had Uregesens, we've had basically a palm up, right? Or a full can in 90 degrees, 90, 90 abduction flexion. And now we're seeing abductions totally fine and going through just pure flexion is worse. So.

Dr. Beau (09:11.416)

Then I put him in a four by four rocking just to have him like sit back on his heels. and he was pretty okay. He's like, whenever he like loaded his, I guess, like loaded his shoulder more. So when he rocked forward and started feeling a little bit more, when he rocked back, he was fine. There's like more load coming off of it, which led me to, since I'm adding compression with that, I put him on his back to go to like some, clicking and catching of shoulders, like a contest, I guess you would call it that. Adding some compression.

And he did have a little bit of a click in his right shoulder. He had a little bit of the same thing in the left, but I'd say it's a little more on the right. Now again, am I still seeing, I guess, previous injury? don't know what his shoulder felt like 10 years ago after the surgery. So that's some of the pieces that I'm not 100 % sure on. But have to go off of what I found in the office that day. And then I also had him on his back. Like you talked about the scapula thoracic lock.

I actually retested Superspinatus, I guess empty can, full can, and he had no pain with his supine. So if you just like, yeah, again, lock his shoulder blade down pretty much, he has no pain with any of it. In case anybody's gonna order this, we call Brooke Bush Institute Check Me. It's a Brian's test with hand up, hand down at 90-90. Oh yeah. So there you go. And then if you're just taking like a peer examination or a presentation of what he looks like,

pretty big like bilateral rib flare, pretty hypertonic erectors, like lumbar erectors outside of that. And I guess more so upper trap, some hypertrophy on both of those as well. But he's also, I'd say like a pretty well built like individual if you want to say. Neuro normal and then palpation. had trigger points basically around his entire shoulder. So like pec minor, pec major, nymphs finitis, teres minor.

Then he has some tone upper trap elevator and then jump restrictions was going to be CT thoracic TL and then right shoulder extension. So I had him face down just pulling his right shoulder back. And he actually said he's like, that actually feels really good when you pull my shoulder back. So pain odds for me would be shoulder flexion active and resisted four by four rocking, which just kind of helps me mimic a little bit of some overhead positioning and push up positioning, which he mentioned were painful. So I'm going to get into our specific testing.

Dr. Beau (11:34.126)

That would be kind of my area that I threw that in and then functional audits I actually am going to go after the shoulder extension first just because that was the That was a pretty big difference side to side along with the previous injury and he also mentioned that it felt really good when you did when I did that and then Because he only had pain when he actively did it so I know I mentioned it was dysfunctional and painful when I had him

go into a paternity pattern one but it was dysfunctional non-painful through passive and then thoracic extension and then the trigger points in the shoulder are kind of my like major three and then the fourth one that I will get to eventually later would be some rotation. So my diagnosis I have is like a laryngeal tear, laryngeal irritation, maybe a little bit of some biceps tendinopathy somewhere in there.

well just because of again all the other big tests that we mentioned just adding up to that's you're checking like fear for that are all around that exact same those structures so treatment wise first day did some soft tissue around his shoulders trying to calm down the trigger points did some start position to also get him to see if he can learn how to just turn off some musculature because he's super like peck heavy when he's just like in that start position

Has like almost zero clue how to do that So I'm like trying to get him to like relax that and he's like I have no idea how to get that work to relax and whenever he does He feels he almost just has to go to like shoulder or I guess a t-spine flexion. That's about the only way he does I like offload his pec So I'm using it for both t-spine extension and some trigger point stuff Five-month sideline for the posterior cuff to try and create some space for the anterior portion of his shoulder to get into creating some rolling motion

to centrate his joint around his shoulder. Then I had the shoulder extensions for my other piece that I had. And then...

Dr. Beau (13:42.114)

I adjusted CT thoracic TL. So homework, sent him home with the shoulder extensions and then some T-spine extension for some foam rolling. Just because that is like super stiff and if I'm gonna get some shoulder extension, I need his T-spine as well to move pretty well. So second visit, he goes to the gym about, I mentioned three days a week. State said his shoulder still has pain when going overhead, but he was able to do some kind of pull-ups and push-ups.

which is improvements from the last time. I think I saw him four days later on this one. So I guess he's been to the gym only one time since I saw him. So shoulder extension had zero change to it passively. Trigger points around the shoulder are the exact same. So it basically feels like we're back to absolutely no, like there's nothing different this visit, but somehow he's able to have no pain during the two movements that were painful from the first visit.

So pain audits changed but functional audits did not. So again, adjusted the CT thoracic TL, especially into the right rotation. And then I did more soft tissue work around the right shoulder. After doing that, I went and checked shoulder extension and that is equal bilaterally. So that kind of gets me into the, you know, did I actually go after like his joint, I guess last time? Or is it more so the musculature around it that was restricting that?

mobility which here I do some soft tissue work without any extensions and it's like boom extensions like clear when you say soft tissue work just for so some stekos some a RT also just to help kind like save my hands a little bit I use the little like massage gun on both sides trigger points or especially around like Terry's minor and around the front of the pack so then it start position again

side lying then moved him to the low oblique kind of start position so he's propped up on his elbow laying on his right side knees bent almost like he's fixing to start a side plank position. Mainly trying to use this position to see if he can drive against expansion between both shoulder blades to try and drive into the ground or t-spine extension or t-spine uprighting to make everyone can throw in there. He's like super shaky just holding that position so I haven't had to move I

Dr. Beau (16:05.016)

he's up onto his knees yet literally just holding that position he's super shaky. So I sent him home with the T-spine foam rolling in this low oblique start position because I was like it's tough enough for you to

I guess like work towards, but you can do it well enough. So yeah, those are my two things that I sent this time. Third visit, he has zero pain during weightlifting, but reports it's only when he lifts it in certain positions. So he has nothing on any of his like overhead pressing, nothing with his pull ups. He's actually able to do some kipping pull ups, push ups are fine. I think he's mentioned as well.

I said this was like a month or so ago. So I think he mentioned they did some like front rack positioning stuff, which he's like, it used to be painful. wasn't anymore. So soft tissue again, feels about the exact same as last as the last couple of visits. Orthos from the first visit are still about the same and still weak. But if I push on serratus anterior, kind of like right underneath his like shoulder blade, and I push on that. And if I redo any of the orthos, he has no pain in full.

full strength. he's like, he kind of looked at me, he's like, that kind of doesn't really make sense. But we had just talked about the, you're basically helping either his shoulder blade or creating him to like some pseudo stability there in his shoulders. Like, yeah, I feel comfortable because I actually have some input here and I feel stable. So did basically the exact same treatment as I did last time, mainly because I, but I added in some rolling here.

In that like low oblique, so I had him pressed up But instead of again rolling up onto his knees I had him still hip on the ground and just rolling as far as he could almost like a crowbar But he's rolling forward Just because I've got to kind of address the motor control aspect because we've shown a couple times here the motor aspect is one of the biggest pieces right if it was like more so a true injury if you want to call it that some of the pieces of like snakebites and shoulder blade and push on certain structures shouldn't I guess make necessarily make it

Dr. Beau (18:12.684)

any less painful or stronger. So my audit shouldn't be changing like that. And then I send him home with the exact same, the exact same stuff as last time. So T-spine foam rolling, that little big start position, but I just did more crowbar action this time. This visit, I also mentioned about him getting like a massage before he saw me, just because I do have to spend a decent amount of time doing some soft tissue around his shoulder. I was like, if you paired it with...

you know, one of our massage therapists here would actually like help me a ton so that I can spend more time on the motor aspect. I don't have to actually dive into the.

once as much. So fourth visit which I'd say this is probably two weeks after I saw him for the first time. He was able to throw the ball as a goalie this week with no pain and now only has pain with pulling movements but nothing with kipping pull-ups. So his pulling movements is going to be your rows. That's about the way time he feels it. Hasn't gotten a massage yet. Rechecked previous syndrome exercises and then I advanced to like bare holds and then did some like hand removal stuff.

to try and see if he can't load this right shoulder, stabilizing some coronal plane and some rotation challenge. He can't perform it on the right side at all. So he just like has no clue how to do it. But yet he checked his left side. He's just like super stable. So like right side, has to like almost like lean completely over into it and will not like basically almost falls over trying to hold that position. So I sent him home with that exercise. And then...

We had about like a two week hiccup here, I guess, where I didn't really see him because we had Christmas and New Year's that was thrown into the middle of all this. So he's like, I didn't do anything for my shoulder over the holidays because he had like 15 people that stayed at his house. So he's like, I was trying to deal with family stuff. So he's about the same as the last visit. This time he finally comes in, got a massage on his shoulder before seeing me and said it felt incredible. But he goes, I felt like I got hit by a bus after that.

Dr. Beau (20:17.486)

So his only discomfort this morning was when he was working out in a single arm kettlebell squat snatch. So he's like, we had some pushups thrown in there. We had some pressing, but the single arm kettlebell squat snatch. that's just literally him just doing a snatch based to catch it super low. Um, so I was like, I just want to see, see what that looks like. would like to know what percentage of people can actually do that exercise. That's why I wanted to see. That's why I had him perform. 1 % of the American population. Cause it was, yeah.

So I had to do, think it was like 10 of those for like four or five rounds. it was, it was a decent amount. was a decent amount of volume for, for that exercise. So I was like, I just wanted to see him perform it for me. Cause I was like, we're now getting into where it's like specific, specific exercises or it's bugging him and not necessarily just everything like it was at the beginning. So it's more of the why, like why are we, why do we keep kind of running into this issue?

Especially in that one like plane of motion like 45 degrees out or so, you know 90 degrees to 100 degrees of shoulder flexion We're still kind of getting caught because he's like when I'm going to go overhead to catch the to catch the snatch He's like there's that pain point but catching it is fine So it's again just that little middle section He cannot get his arm all the way overhead because he was like because I asked him how much he was using I was like that I was using 30 pounds to do this I was like, well, here's like a 10 pound weight. Let's just see if you can do with 10 pounds

can't get his arm all the way overhead, upper trap heavy so when he goes to pull and the whole time he's doing it, it's just, I he's just laying into his right upper trap, has to lean super heavily onto his left side as well in order to do it because he just can't rotate enough to the right to catch this. So recheck the bare hand removal and was able to crush it this time. Lumbar lock with right rotation with dysfunctional non-painful on the active component but was functional non-painful with passive.

So we've kind of cleared that joint restriction. It's just the active component he cannot do. So I had him do the overhead position. So like a little half kneeling kettlebell windmill. So he's in like one knee. So left knee would be down, right knee up, right arm has a kettlebell overhead to work on this catch position, but also some right rotation. And I had him do this and he's like, there's no way I'm getting to the ground on this. He's like, I can't even get there.

Dr. Beau (22:44.044)

And he couldn't get to the ground with his hand for the first like three or four reps and eventually started getting to where he could. but the only way to get to the ground, had to like roll super heavily onto the outside of his foot. So I was like, let's just chunk that for right now. They're going to able to supine position. I guess like legs up almost like you're in a three month position and he's having to hold the kettlebell in the right hand and do like windshield wipers to learn how to like let his body kind of rotate one direction and back, keeping the shoulder.

on the ground. So did I think like seven of those reps with his legs going to the left and then had him go back and recheck that little supine or the half kneeling windmill. This time he like crushes it. So he just like boom straight to the ground and comes back up. It's still difficult, but he at least has like, oh yeah, that feels like way better. And then I had him recheck that little kettlebell squat snatch. And he's like,

It feels much better to do, but it's still difficult to get his arm all the way overhead. So I sent him home with that little supine rotation because he's like, have some kettlebells at home if I can do this. So I just used what he had. I even said, hey, you don't have to have any kettlebells or any weights to do this with. And then for warmups in the gym, I actually have him doing the little half kneeling, half kneeling windmill.

And then I asked about like some upcoming training and games and told him for the current moment to eliminate overhead pressing since he's going to be playing a decent amount of soccer coming up. And since we're trying to address the overhead component of rotation, just to like not keep like bugging the bear since a lot of the overhead stuff is still still kind of clocking him. But he scheduled to come back in early next week. So that's kind of where we're at with his case. there's kind of two big things that stood out throughout there.

yeah, you're probably all over the diagnosis. So then, you know, I've done, I did a podcast, which I'll put a link in here, to a podcast that it was Steve Coppobianco. And I actually did a talk on this at the rehab symposium in Orlando this past summer. I'm like, why, why are trigger points forming? And there's, you know, a couple of hypothesis, like a sub-threshold workload, neurologic protection of an injury.

Dr. Beau (25:07.721)

sensitization. So then you talked about, that's why I asked the question of like, what soft tissue are you doing? So we, when we throw the kitchen sink at stuff, so we're like, oh, I a little stecho, did a little ART, did a little, you know, basically like percussion. Those are three different mechanisms, right? Stecho, you know, maybe they're all creating the same effect and we just don't understand stuff well enough. But let's say it's sensitization that automatically changes the bullet that you put in the chamber, right? So you're like, man, if I go in there and blast it with stecho, it might get more sensitive.

And the reason I bring that up is what did he say after he had a massage? He's like, feel like I got hit by a truck. So the light and what was the one thing that kept not changing? The soft tissue component. So again, you always are trying to ask these questions and I'm not saying I know, don't, neither one of us know, but you start to try to guess better of A, why is the shoulder, you know, have a much higher tendency and trigger points in it to begin with. Second, why isn't it changing even though, you know, pain is changing and function, other function is changing. Then you kind of say, well, God, why did he get so, you know,

have so much soreness from a massage. And then you're starting to say, man, there may be sensitization. And that leads you to, well, why is it sensitive? And then you gotta deal with that. Does it help you or is it just kind of like, it's a thought process. But you're always thinking about that stuff. And again, I highly encourage you to look up the research on this stuff. I've done a whole research review on trigger point stuff. So yeah, go look that stuff up and start asking those questions yourself. The other thing is if you kind of work,

You know, throughout his whole treatment plan, all of his homework, I he was always like, foam rolling his T-spine. He got a T-spine rotation, came down towards the end there that basically he had, you know, passive rotation. If you, you know, get rid of the lumbar spine, but he's still actively really couldn't figure it out. So then it also kind of begs the question, even though there was stiffness in his T-spine, if, you know, let's say in a magical world, we could have Gray Cook come look at this guy from day one, you know, in parallel of what you're doing. And he's like, God, there's just a...

thoracic spine motor control issue, right? And that's what he's working with from day one because then, maybe that's, and then you're like, why is it right shoulder? He had an injury, right? So then we got always, which we talk about this a lot, like rule out pathology and legit injury. you treat the area, but then it leads you back to, again, this is the biggest issue. And I think that's what you landed on because it's, you don't get better in exercise over reps, right? And it's not loosening. It's like you're figuring out.

Dr. Beau (27:30.574)

So it's not that something's actually changing. It's just you're kind of taking the parking brake off a pattern. We're establishing a new pattern. So I think that's kind of a good thing for people to see or hear, I guess, that you did work on a shoulder because you had trauma. So you had to calm it down. And you're like, that's why when I have a shoulder extension, I have to get it moving. That shoulder extension popped back after the first visit, didn't it? Yeah. Then after that, you're like, I got to keep changing the things. And you keep working around the shoulder, soft tissue and stuff, but it comes back to thoracic spine, thoracic spine, because it keeps showing you that.

When you're dealing with the injury, it's like we always talk about you need to go off the biggest thing for functional audit But again, he's still like in pain really can't really do much of the gym But he also was playing soccer and even this first thing. Hey, I've got some soccer matches coming up I don't want us to be able to play as a goalie Like do you think I'm gonna be able to do that? They asked me they've already texted him and asked him like before he saw me if he was gonna play this weekend So it was kind of like I'm gonna do everything I can to kind of like

calm this down as much as possible and not just add more fuel to the fire. Because if I'm trying to change, let's say his function, it's kind of like a baseball player. If I go in and I dry needle a trigger point in his lat or something like that and he goes out on the mound, that should open him up to a potential for more injury if he's going to continue playing. Is that there for a reason for a protective component? So was like, let's just add something easy to go after his shoulder extension needed to get worked on.

There's other pieces that, like I said, we led to, but there was so much, guess, I could have worked on on the first visit. It's like, let's just start kind of locally around like where it hurts. And then we can expand once he's able to like get back against a little bit more like normal routine to an extent. that, I think you're allowed to be a lot less worried about like changing function by going after something. So, you know, if you, we always hear the horror stories of changing stuff in a pro athlete. We're not dealing with pro athlete here, first of all. Second thing, this is goal alignment.

you matched what he said he needs to be able to do with what you did from treatment because you could have just went after a thoracic spine and not a shoulder if he's like, I'm not gonna be doing anything for the next month. And that's what you have to weigh it against is like, I'm gonna be doing this. I'll be like, then your shoulders are gonna be able to do different things very quickly versus if you thought, know, we have multiple, I mean, the next case I'm gonna talk about like same thing, right? This guy's job is a physical job. And it's like, okay.

Dr. Beau (29:53.838)

you we have to make this decision because of what you want to do, not necessarily what I think needs to be worked on. That's in our world, very different than you got an MRI, you see an orthopedic surgeon, you have a torn tendon, they think they need to repair the tendon. And that's regardless, most of the time of what you have coming up, just because it seems like drastic, even when it's non-traumatic tears that just been around for years. So that's our job is to determine goal alignment of what do need to do? How much time do we have? What are you willing to do with?

hey, we think there's a little bit of injury or not, and then how much time is it gonna take to change this function and things like that. So it's kind of a big equation that you're trying to know, weigh both sides and make them even, but it's never gonna be even. The other thing too is, like you said, aligning with his goals, like.

There was no part, I guess, to the exam where I felt like he needed to not do any of those things. If he had a true injury, felt like most people would be like, all right, how long do I need to sit out? His was more like, am I gonna be able to play? And he also mentioned, he's like, yeah, he also didn't say that he was gonna cut back any of the gym. He's like, yeah, I'm still going three days a week. So it's kind of like, you're still staying pretty active, it's just bugging you and you're kind of getting annoyed by it. That's the other piece too.

So the case that I talked about at length last time, which I'll kind of still give like a five minute overview, but somebody I've seen for a long time, they've had a multitude of injuries all over because they own or partial on a Taekwondo gym. They coach, they're sparring all the time. They compete themselves, likes lift weights. Super interested obviously in the movement world because of he does. So it takes the advice, but then also

you know, not to be mean, it's kind of stuck in a bro weightlifting mindset. And I think some of that's kind of his detriment with Taekwondo. It's just, there's a bad intersection there. So anyways, I've seen this guy for a long time. One of his constant complaints just kind of his shoulders will bother him, you know, right shoulder, left shoulder on and off on and off over the past couple of months, his left shoulder has become more more bothersome to the point where he started telling me I can't do lateral raises. I can't do front raises, which

Dr. Beau (31:57.774)

I hate to say there's bad exercises. There's a lot of laboral sheer with those exercises been proven if you're not in the angle of scaption. And it's not like we have to do everything in these safety ranges, but it's kind of like doing bench press with your elbows at 90 degrees. We just know that's not the best thing for your AC joint. All right. So if we get into the same angle of scaption and like a pushup or a bench press, it's a little bit better. Now, if you break your arms apart and they're in dumbbells, it's even better, right? So there's just these like things with exercise where you're like, it's not bad or good. They're just better options for most people.

So I tell him, hey, let's just not do those things. Let's do 45 degrees. Let's do more single arm pressing with kettlebells to see if we can calm it down because I know at the crux of this guy's issue is a bunch of rib cage stiffness and it's thoracic spine stiffness, but it's how this guy's rib cage basically is stuck like you said with your guy in kind of this inhalation schema where it's just flared up and he has excessive tension around his lats like a lot of people. So now he's stuck in extension.

He can't get his shoulder in full flexion. So when he gets to the top of the shoulder range motion, I mean, if you think about the angles here, think about your rib cage being tipped back and then your shoulder still can't get over head. I mean, you're just basically leaning on the back of your shoulder at some point. And what's the catching in the front? Usually your bicep tendon. So he's telling me all this stuff and I'm, I wouldn't say I'm being laissez faire, but I told him right away, I was like, yeah, I think your supra-cenaeus is kind of bugged. It's not torn, but like it's for sure bugged just based on, know.

what's, don't even know, push button task, because it's bursitis, but like pushing where the tendon is right to the medial aspect of your AC joint, empty can. Doberns, I think it's pushing something. Push button, Doberns, think we were pushing on like for bursitis, which is terrible, it's so stupid, it's not funny, but anyway, we're going through this and I'm like, yeah, it's kind of bugged and I'm not really worried about it because.

huge functional things to work on to allow this guy to do stuff. And he's doing stuff that isn't awesome for your shoulder anyways, especially he's sparring and doing all this other stuff. So I keep, you know, coaching like, let's go after rib cage, rib cage, rib cage. And it was tracking along well then last visit, which would have been a little over two weeks ago as of today. He comes in and he goes, you know, his Achilles had been bugging him. He's like, that's been better. He had an oblique strain on his right side, which ties into the rib cage stuff. goes, that's better.

Dr. Beau (34:16.161)

because this lift shoulder is just, it's really starting to bug me. And he goes, and he says, you know, do you think we should get an MRI or something, which is like a light bulb for any clinician of like, when they say that, they're basically saying like, I need some confirmation now. And if you, I'm not saying you can't talk your way around that back to function, but if you went, you know, at this point I'm three visits in specifically on the shoulder. So I'm getting into a trial of care. If you're not having success in terms of like,

relieving their pain, getting them to do what they want to do, goal oriented stuff, and they throw the flag of, I think I need an amateur console. You better listen to that, otherwise you're going to lose them. And I don't run the risk of losing this guy. He's like notoriously my biggest fan, and maybe the loudest patient in the office, but lose them from that care. Like he just goes to somebody else, I'm like, dude, my shoulder had so-and-so and you didn't know. So I kind of say, hey, we can get him right. That's totally fine. I don't bring anything up about North Beat console. I go,

On that MRI, it's going to show a small slap tear and it's going to show some like tendonitis or a partial tear of probably supraspinatus. And that's just kind of your right shoulder might have the same thing. just doesn't hurt as bad. And goes, I get it. get it. And then he like, you could tell he's like, yeah, I just need, you know, really need to know. got a lot of stuff coming up and like love that I did that. So the MRI, what was it? A little bit of AC degeneration, mild tendonitis, supraspinatus, small slap tear. And they literally said small slap tear and it's the head of radiology for.

the hospital around here. So we tell them that and because I knew that if there were positive findings of what I said it was, even though I think it's a rehab scenario, what I'm really leaning on now is I think those findings don't warrant surgery. So I went ahead and sent them to the orthopedist that is our conservative kind of orthopedic arm with no like, I wasn't teeing up the orthopedist like, hey, let's not get him out of surgery. Hey, go have a consult because I need to be able to trust that guy.

Now if he says it's surgical, I will call that orthopedic surgeon or orthopedic doc in this scenario and be like, why is this surgical? There's no tear in the tendon, tendonitis, and we have a small slap tear. So now hopefully we get an orthopedic surgeon to tell this guy, hey, it's not surgical, you need to do rehab, maybe give them some medication, don't know, injection. But what we get is this massive confidence influx of like, okay, I'm headed the right direction.

Dr. Beau (36:39.724)

His shoulder could feel better next time he comes in just because of that. Because you're managing the case appropriately, he feels more confident. Maybe he does lay off stuff even more because two people have told him and technically somebody I guess higher in the echelon of triage. But it's a big management case because I know I could have just like kept him going and he'd keep getting frustrated because he does so much stuff from a goal misalignment where I'm like, dude, can you just lay off? And he just doesn't. For part he can't because of his job.

part he doesn't want to because he just wants to grow out. So it's a good case because I was diagnostically accurate, which gave him confidence when the images matched what I told him it was. That's not always gonna happen. Second, like Seth said, I knew it wasn't bad enough to need to just stop anything. I was just trying to modify stuff to A, not make the injury worse, but B, get him out of pain faster. Last thing is,

I knew I needed to work on this core functional deficit of rib cage, just general movement and basically 3D, but mainly rotation with him. you think about somebody with Taekwondo, doing a ton of rotation. This guy's had multiple oblique strains. So now what do I get to do when he comes back in? Yeah, I'll ask him about a shoulder. Maybe he got Mlock's camera cellbrack or something or an injection. But I get to go, hey, we're just gonna let your shoulder chill out. So we're just not gonna do that stuff of picking the scab and we're gonna hammer your rib cage.

And now I get this big aggressive four or five visit slam of like, you should be sold on this, right? So that's what we're trying to do with all these cases is manage them so well that they come to the conclusion, which we're giving him info for him, but he comes to conclusion, my shoulder's beat up, but it's okay. Bo said I gotta work on this stuff. And the ortho that we sent him to also talks about dietary changes, anti-inflammatory supplements, all the stuff that I've told him, so.

You get these echo chambers in a good way. But again, I don't know, he hasn't had, or I don't have the notes back, we checked right before the podcast. I don't have the orthopedic notes, I don't know what he's told him. I can only cross my fingers that he did not say, hey, let's do surgery. Now, if he had to do a surgery, and I even went over this with the patient, he goes, what's the surgery like that look like? And I said, with a small labral tear, they'll go in and they'll, you know, one or two sutures, you know, maybe not even, I don't know. That, maybe they clean it up.

Dr. Beau (38:59.956)

One or two sutures and if it's small tear, mean four weeks and you're not back to full go, but you should be out of like post-op PT and back to kind of training at a low level. So we'll just see, but I will for sure do a legit follow up since we didn't have the previous podcast and we're back here because of lost audio. Yeah, just review diagnostically accurate, managing the case well, and then working on, know, the thing is the thing is the thing, like working on what you need to work on in the face of an injury or not. And that can be really tough as a clinician at any phase of your.

career. So, hope that helps. Any more to add on his case or your case? Any thoughts come up while I was talking? I think the toughest part is again, like making sure that you still are addressing your biggest functional audit even in like you mentioned the face of an injury. Yeah. Right. Weighing the odds of not the odds, but weighing the, is this more of like, okay, I need to refer this out for like a...

some other type of intervention, right? Surgical versus like imaging, right? Not being nervous to pull that too early. Cause there's two cases where we have like very similar, I'd say presentations for both of us, but it's, you referred for imaging and I didn't, but yours was because he wanted it. And mine was like, mine did ask about it because he asked, goes, at what point do you consider getting imaging? So at that point it still kind of lands in my ballpark of like,

He trusts me with his care and understands and I just walked him through like, if the weakness continues and then it starts to affect your daily life and or pain slash audits are not changing, that is where I will start being like, hey, we need to go out and do these things. But if I can push on a different part of your body and make those changes where you have full strength and no pain to me, that doesn't warrant you having surgery. If you thought about it like this, if every one of your patients was gonna have

surgery or some high level medical intervention for every injury that they had. Let's not say it's like chronic pain or it's like legit like, you know, tendinopathy, a tear, whatever it is, an injection even for like neurologic sensitivity. Like there was some high level intervention where you're like, the injury is being treated. That's how you should treat everybody. We have tools to do that stuff too, right? Dry kneading for pro-inflammatory markers, offloading tissues to let them heal. Like we're doing that in our own way. So I'm not saying you're not treating the injury.

Dr. Beau (41:20.814)

But just imagine, play the game for a month. I know it's a lumbar disc herniation, I'm gonna send them out for a discectomy. That's just what you're playing in your head. What would you be treating when they came back into your office? If you play that game, you'll start being like, I probably wouldn't be just shoving them in a lumbar extension. Because if that was your answer, post-discectomy for somebody that's like, God, I still kinda have a little bit of radiation in my hip.

You're not gonna get anywhere with anybody, I promise you that. You're gonna be treating pain, you're gonna get lost in the mix and be like, and then they're gonna have another intervention, they're gonna come in and you're be like.

And that's, I mean, it'll happen to you, it happens to all of us, but that's how I would have you think for a while. And that's why you have to be so good at ruling out or ruling in injury to know, do I need to do some things for the injury or hey, my big job is to offload that tissue, offload that joint through the functional capacity or functional changes because it's just kind of getting irritated. Which you said, like tear or irritation goes one way, you know, maybe a tear comes in it. And let's say you get an MRI, let's say my guy, you flip the script.

His MRI is clean as a whistle.

I hope you weren't working on his labrum. Good luck explaining that one. So, and again, it's not to say that sometimes the thing is you could be working on somebody's shoulder and they have a shoulder shoot. Yeah, but you better have some information that led you there instead of just like, your shoulder looks like we're under a shoulder. Because what if Seth was just stopped at shoulder extension? This guy go gets an MRI and his shoulder is just fine. And now Seth has to reconcile with him. The guy's for sure gonna be like, what's wrong? You're like.

Dr. Beau (43:01.486)

And let's say a shoulder extension got better and that's us like, I don't know, we got shoulder moving and there's nothing wrong, I don't know. Maybe you have chronic pain, which I think happens a lot. You just run out of data, basically. So I run that experiment. If you run that experiment, you're somebody that listens to the show, like tags on social media or something with, I don't know, to hashtag function over surgery or I don't know, fake surgery, sham surgery function, something, we'll think of a good hashtag.

The thing like that, I think it'll help you quite a bit. I think it's a good way to think though. You just think the injury will be taken care of. And again, sometimes that is your job. Sometimes just chill, but think of it like that. And I think it'll flip your mind real quick and like, oh, I'm a tree over here. And there's other reasons that you wouldn't treat a hotspot. This guy, when he got a massage, shoulder, I wouldn't say it was worse, it hurt. Cause I wouldn't say that. mean, like I'd be lying if I said I didn't walk in there every time and being like, I'm getting an MRI today.

I walked into the room being like, based on how he is and just kind of knowing how he acts, like his mannerisms in the treatment room, I'm always like, yeah, we're getting an MRI today. And then I go and check things and he's, as we're rolling through things, the MRI starts coming down lower on what I'm gonna order, just because what he's telling me and function and what I'm feeling. It's like I'm walking in on this being like we're getting an MRI today just because he's had a previous surgery to that same shoulder with the same injury. like.

He knows things about his shoulder because he's been there. You can go too far the other way. You could have too much bravado behind. I'm not like with my guy. I don't need no MRI. And he comes at me with like, and you're like, you don't need one. Even if there was a small tear, it'd still be rehab based. That might be what you legitimately think. And you would say behind closed doors, that is not the best way to manage that case for 99 % of people.

Most people, you get a pro athlete that's gotta go through a season and you know, this gets talked about a lot. So let's put somebody with the exact same pathometatomical diagnosis of my guy, a small labral or a small slab tear, a little bit tendonitis, a little bit AC, and let's say they're a pro quarterback and it's a week before the season and they fell. Outstretched arm going for quarterback sneak and they come to you, this is probably not gonna happen, but a pro athlete, they come to you and you have to make what decision?

Dr. Beau (45:22.734)

Could they play through it? How much do I tell them? How much does it warrant telling them to not let them worry about it? How fast can I get them good? What would they not be able to do? Because in that scenario, you're talking about millions of dollars, playoff, like all these things come into play. We talked about that with pro athlete, like why shouldn't you treat everybody like that? Like goal alignment, like what do we need to do? It makes sense sometimes to be like, I know they have this going on, but I'm not gonna give them the full rundown. like, hey, there's a giant tear in your shoulder, but I think we can rehab it. Just be like.

Short is a little angry, but you know, doesn't get better, we can get an MRI. Like you choose your words, which is again, management. And I'm telling you, you're gonna have to make those decisions too, you know, based on personalities, previous experiences, chronic pain scenarios of not saying the same thing in almost the exact same scenario. And that just takes clinical, you know, awareness, which here's a pitch for the art of assessment. We just went over module one, which was introduction. Module two is on observational skills.

both in the treatment room and outside. And we talk a lot about the different levels of awareness. know, one of those gets into just general awareness, like emotional, you know, intelligence and being aware of the scenario that you're dealing with rather than just like, you got your ideas, you spit them out, regardless of who's sitting in front of you. Best clinicians in the world are really good at managing people. They're good with their hands, they're good at diagnostics, but they're amazing at managing people in the face of maybe not having some of the skills that other people do.

That's on bobeer.com, our assessment hybrid will be doing a live module next week and then we'll also next week interview 41, which will be recorded in two weeks. We're going to allow, if you're part of that, you can be on that show and ask questions. We might even have somebody from that cohort present a case or something like that. So look forward to that. Any last words? Thank you. See ya.