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Staying Afloat, Keeping the Wheels Down and Feet Forward


... PRICES Kinesiotaping and Compression Hose Orthotics cast Manipulation/Mobil. Of Foot, Ankle, Knee, Hip and SIJs Clear out imbalances _at_ External rotators of ... – PowerPoint PPT presentation

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Title: Staying Afloat, Keeping the Wheels Down and Feet Forward

Staying Afloat, Keeping the Wheels Down and Feet
  • Prevention and Management of Repetitive Stress
    Injuries in the Triathlete
  • Dr. John L. Michie

  • Certified Chiropractic Sports Physician
  • Certified in Physiological Therapeutics
  • Certified Exercise Physiologist
  • Certified in Clinical Nutrition
  • Certified Myofascial Dry Needle Therapist
  • Certified Functional Medicine Practitioner
  • 20 years in clinical practice working w/athletes
  • 2,000 hours of post doctorate education

Program Highlights
  1. Mechanisms of Injury
  2. Applied Kinesiology and the Kinetic Chain
  3. Connective Tissue Support
  4. Managing Inflammation
  5. Self Corrective Measures
  6. When to Seek Treatment and What Modalities are

Common Injuries of the Triathlete
  • Runners Knee/Patella Femoral Syndrome/Chondromala
  • Achilles Tendonitis
  • Swimmers Shoulder
  • IlioTibial Band Friction Syndrome
  • Sciatica (Discogenic and Piriformis)
  • Sacroiliac Syndrome
  • Plantar Fasciitis

Common Injuries of the Triathlete
  • Medial Tibial Stress Syndrome
  • Meniscal Tears
  • Adrenal Fatigue
  • Degenerative Disc and Joint Disease
  • Lower Extremity Stress Fractures
  • Rotator Cuff Tendonopathy

Ken Hutchins Exercise is not an Adjunctive
Therapy, Exercise is the Therapy.
Mechanisms of Injury
  • Repetitive Stress Trauma
  • Triathlon training consists of massive repetitive
    stress to multiple body regions!!
  • All endurance training consists of repetitive
  • In RST, Connective Tissue failure occurs due to
    excessive loading and/or poor biomechanics

Mechanisms of Injury Connective Tissue
  • Tendons connect muscle to bone and transmit
    mechanical energy
  • Ligaments connect bone to bone - denser and
    provide some shock absorption
  • Myo-tendinous Junction is a transitional area and
    highly vulnerable to injury
  • Tendons and Ligaments are largely made up of

Mechanisms of Injury
  • Exhaustive Endurance Training creates damage via
    metabolic disturbances and ischemia! (Ischemia
    Induced Muscle Damage) restoring blood flow
  • Muscle Contusion injuries (Swim?) may lead to
    excessive fibroblastic activity and formation of
    bone within the muscle

Mechanisms of Injury
  • Stretch Injuries occur when the movement exceeds
    the flexibility of the joint/ligament capacity
    resulting in micro-tears.
  • Biomechanical imbalances are the underlying
    causes of most soft tissue related injuries!
  • The Kinetic Chain is integrated and if faults
    exist anywhere there will be an insidious
    development of injury at or remote to the fault
    site! JLM

  • Cardinal Signs
  • Heat
  • Swelling
  • Pain
  • Redness
  • Loss of Function

Inflammation and Repair
  • Remove inflammatory debris by Phagocytosis
  • Granulation/Scar Tissue Formation
  • Tissue Remodeling 6 days post injury
  • Collagen is laid down randomly
  • NSAIDs interfere w/collagen formation!

Inflammation and Repair!
  • Immobilization of a healing injury compromises
    strength and collagen orientation
  • Mobilization results in stronger, faster healing
    of connective tissue injuries!!
  • The greater the amount of injured tissue, the
    more scar tissue deposition

Inflammation and Repair!
  • Ischemia-induced Muscle Injury is caused by
    damage to vessels seen in endurance sports
    (Compartment Syndromes)
  • Extent of injury proportional to duration of
  • Nerve injury may result due to persistent
  • Can result in excessive scar tissue formation and
    cell death
  • Kinetic Chain imbalances lead to over-utilization
    of muscle groups and this may lead to ischemia

Inflammation and Repair!
  • Inflammatory Response Time Frame of Healing
  • Acute phase 24-48 hours
  • Proliferative phase 3-7 days post injury
  • Repair phase few days to few weeks
  • Remodeling phase several months..

  • Negative Effects of Immobilizing Injuries
  • Cartilage deterioration
  • Bone strength/mass loss
  • Ligament strength and pliability loss
  • Adhesion formation magnified
  • Muscle atrophy
  • Longer rehabilitation windows

Treatment Protocols
  • Acute Phase
  • Goal Control Pain and Inflammation
  • Protect
  • Rest
  • Ice
  • Compression
  • Elevation

Treatment Protocols
  • Physiological Therapeutics
  • Ice 30 minutes per application (Avoid Hunter
  • Electrotherapy (IFC, HV, etc.)
  • Ultrasound (Pulsed Continuous)
  • Iontophoresis
  • Moist Heat Post Acute Phase

Treatment Protocols
  • Joint Mobilization/Manipulation
  • Stimulates mechanoreceptors
  • Decreases joint congestion
  • Relieves compressive forces on articular
    cartilage and structures
  • Relieves contracture of tissues
  • Breaks down adhesions
  • Enhances biomechanical alignment

Treatment Protocols
  • Soft Tissue Mobilization and Cross Fiber massage
  • Breaks down scar tissue and adhesions
  • Activates phagocytosis
  • Creates fiber re-alignment
  • Accelerates healing and minimizes re-occurrence!!

Treatment Protocols
  • Biomechanical Adjustments
  • Restores optimal kinetic chain alignment
  • Facilitates biomechanical integration
  • Resets neurological firing patterns
  • Stimulates healing and joint function
  • Reduces pain
  • Minimizes re-occurrence

Treatment Protocols
  • Kinesio-taping
  • Mechanical Correction Recoiling
  • Fascia Correction Holding
  • Space Correction Lifting
  • Ligament/Tendon Correction Pressure
  • Functional Correction Spring
  • Lymphatic Correction Channeling

Nutritional Management
  • Anti-Inflammatory Protocol
  • Avoidance of Sugar, Trans Fats, Grains and Dairy
    (Grain fed animal products eggs also inflame!)
  • Increase Hydration!
  • Proteolytic Enzymes 3-6 tid w/o food
    (Vegetarian and/or Non-Vegetarian) Trypsin,
    Chymotrypsin, Bromelain, Papain (Wobenzyme,
  • Omega 3 Fatty Acids/Fish Oil 6-9g/day

Nutritional Management
  • Ginger, Boswellia, Turmeric (Cox 2 Inhibitors)
    (Inflavonoid I.C.)
  • CoEnzyme Q10 100-200mg/day
  • Mixed Anti-Oxidants
  • Mixed Bioflavonoids 2-3Kmg/day
  • ALA (Flax), Chia
  • GLA (Borage)
  • Willow Bark Extract
  • Devils Claw Extract
  • 30-90 day high dosing for pharmacological effects!

Connective Tissue Integrity Nutritional Protocol
  • Amino Acids (Glycine, Proline, Lysine)
  • BCAAs (Leucine, Isoluecine, Valine)
  • Vitamin C
  • Mixed Bioflavonoids
  • Green Lipped Mussels
  • MSM
  • Horsetail Extract (Silica)
  • Hyaluronic Acid
  • Glucosamine/Chondroitin Sulfates
  • Manganese
  • (Collagenics, Ligaplex I and II)

Runners Knee
  • Causes
  • Pronation
  • Q-angle (Women gt Men)
  • Quadriceps Imbalances/Weakness
  • Tight Hamstrings and ITB
  • Short Hip Flexors
  • Road Pitch Repetition
  • Overly Supportive Training Shoes
  • Wearing Training Shoes beyond 400 miles

Runners Knee
  • Symptoms
  • Pain behind and around the Patella
  • Pain with walking, running, squatting, kneeling
  • Increased pain with downhill running
  • Popping, grinding in and around the knee jt.

Runners Knee
  • Management
  • Acute Physiotherapy protocols (Iontophoresis)
  • Nutritional Anti-inflammatory protocol
  • Strengthen Quadriceps
  • Myofascial release and foam roller _at_ Hamstrings,
    ITB, Hip Flexors
  • Orthotics for foot imbalances, pronation, etc.
  • Pool Running
  • Evaluate Shoes for wear patterns, breakdown, etc.
  • Manual manipulation, alignment of kinetic chain
  • Bracing for Patella stabilization and compression
  • Proprioceptive input training with balance board
    and bosu ball

Achilles Tendonitis
  • Causes
  • Reduced Flexibility or weakness in Calf Group
  • Overuse or increased training intensity or volume
  • Less recovery time between running sessions
  • Increased hill or speed work!!
  • Unequal leg length
  • Pronation or Supination
  • Ankle or Foot Joint Fixations
  • Poor Heel posting, poor shoe selection!
  • Antibiotic usage (Quinolone group) ?
  • Cortisone
  • Poor warm-up habits

Achilles Tendonitis
  • Symptoms
  • Pain behind ankle
  • Pain just above the heel
  • Increased pain during exercise
  • Point tenderness over Achilles Tendon
  • Worse in AM or after rest
  • Scar like bump formation or thickening

Achilles Tendonitis
  • Management
  • Anti-inflammatory nutritional protocol
    connective tissue support
  • Ultrasound 4-6X/week!
  • Iontophoresis
  • Myofascial Release (Foot, Calf Group)
  • Manipulation/Mobilization of Foot/Ankle/Knee
  • Dry Needle Therapy
  • Orthotics
  • Improve heel posting
  • Heel Pad/Lift
  • PRP??
  • Dorsi-Flexion Night Splint
  • Avoidance and H2O running
  • Traumeel topically 3X/day

Swimmers Shoulder
  • Causes
  • Faulty Stroke Mechanics
  • Increased training intensity and/or volume
  • Micro tears from overuse
  • Excessive of Freestyle swimming
  • Weakness in Upper Traps and Serratus Ant.
  • Weakness/Tightness in Posterior Rot. Cuff
  • Hyper-mobile Shoulder

Swimmers Shoulder
  • Symptoms and Signs
  • Pain with Freestyle
  • Forward Shoulder Slouch while sitting
  • Winging of Scapula
  • A.C. Jt. Tenderness
  • Biceps Tendon, S.S. Tendon tenderness
  • Reduced strength in S.S. and I.S. muscles
  • Moderate shoulder Jt. laxity

Swimmers Shoulder
  • Management/Prevention
  • Establish bilateral breathing pattern
  • Employ symmetrical body rotation
  • Avoid Thumb First H2O entry
  • Employ flat hand, finger tip first entry
  • Open up chest muscles
  • Think shoulders back, chest forward
  • Avoid midline cross over at front of stroke
  • Employ High Elbow Catch and Pull Technique
  • Strengthen External Rotators for Scapula
    Stability (Shoulder Horn!)

Swimmers Shoulder
  • Management/Treatment
  • Nutritional Anti-inflammatory protocol!
  • Electrical Stimulation
  • Trigger Point Therapy
  • Iontophoresis
  • Dry Needle Therapy
  • Mobilization/Manipulation (Cervical, thoracic
    spine, shoulder, scapula, elbow, wrist/hand
    upper kinetic chain)
  • Myofascial release Tx. shoulder girdle,
  • Topical Traumeel
  • Shoulder rehabilitation protocol for A.C. Jt.
    Decompression (see shoulder rehab protocol)

ITB Syndrome
  • ITB Acts as a Stabilizer during running
  • Causes
  • Road Pitch Running
  • Excessive Pronation/Supination
  • Leg Length Discrepancy/Pelvic Un-leveling
  • Varus knees (Bow legged pattern)
  • Gluteal Quad Tightness/Weakness
  • Inadequate warm-up and/or cool down
  • Excessive Hill running (up or down)
  • Toed in position in cycling
  • Excessive Breast stroking
  • Excessive wear on outside heel edge of running
  • Weak Abductors (Glute Med.)

ITB Syndrome
ITB Syndrome
  • Symptoms
  • Pain _at_ lateral aspect of knee
  • Pain below knee (lateral aspect attachment)
  • Pain _at_ lateral lower thigh
  • Pain _at_ lateral hip
  • Pain increases with descending stairs and
    transitioning up from sitting
  • Pain increases with heel strike

ITB Syndrome
  • Management/Treatment
  • Topical Traumeel (DMSO) Biofreeze
  • Correct biomechanical distortion
  • Orthotics cast to correct pedal imbalances
  • Kinesiotape knee and/or hip
  • Transverse Friction Massage
  • Physiotherapy modalities (EMS, Ultrasound and
  • Chopat type stabilizing brace
  • Myofascial release _at_ Gluteal group, Quads, Lat.
    Hams, Gastrocnemius
  • Restore strength to VMO to facilitate medial
    glide of patella
  • Foam Roller!
  • ITB Stretches

  • Discogenic Bulging or herniated disc causing
    compression/irritation of sciatic nerve.
  • Piriformis Deep Gluteal muscle causing
    compression/irritation of sciatic nerve

  • Symptoms
  • Pain in gluteal and/or down back of thigh and leg
    into ankle/foot
  • Burning/aching/tingling down thigh/leg/foot
  • Weakness and/or numbness down extremity
  • Constant pain in unilateral gluteal muscle
  • Hip Pain
  • Increased pain with straining, cough, sneeze

  • Symptoms (cont.)
  • Diff. Diag. with Piriformis
  • Pain/dull ache in gluteal
  • Pain after prolonged sitting
  • Pain increases with stairs or inclines

  • Causes
  • Spinal Stenosis
  • DDD
  • DJD
  • Spondylolisthesis
  • Disc Herniation
  • Trauma to back and/or hip/gluteal region
  • Training with mechanical imbalances in kinetic

  • Treatment/Management
  • Diff. Diag. with exam and MRI
  • Discogenic
  • Electrotherapy (EMS, Iontophoresis)
  • Traction, Inversion Tx.
  • Aggressive Nutritional Anti-inflammatory
  • Correct Biomechanical imbalances
  • Dry Needle Therapy and Acupuncture
  • Training modification/low impact
  • Resistant cases Prescription NSAIDS, Prednisone,
    Muscle Relaxers Epidural Injections, Surgical

  • Piriformis
  • Trigger point therapy
  • Myofascial release tx.
  • Correct biomechanical imbalances
  • Electrotherapy (EMS, Ultrasound, Iontophoresis)
  • Dry Needle Therapy
  • Orthotics and/or running shoe modifications
  • Foam Roller!
  • Piriformis stretches
  • Epsom Salt Bath
  • Kinesiotape

Sacroiliac Syndrome
  • Large joint connecting the sacrum to the ilium
    bilaterally via ligaments and cartilage
  • Symptoms
  • Pain over one SIJ
  • Referred pain to the buttock, hip, groin and
    posterior thigh
  • Tenderness over the SIJ

Sacroiliac Syndrome
  • Causes
  • DJD Changes
  • Pregnancy late effects
  • Pelvic Un-leveling
  • Pronation
  • Poor shoe selection extended wear
  • Road Pitch
  • Excessive tightness in LB and/or Hips

Sacroiliac Syndrome
  • Management
  • Diff. Diag. with exam (Gillet, provocation)
  • X-Ray
  • Correct biomechanical imbalances
  • Orthotics and/or modify shoe wear
  • Gait Analysis
  • Spine, Hip, Foot, SIJ Mob./Manipulation
  • Foam Roller _at_ Gluteal group, lower back, hip
    flexors, hams and quadriceps
  • Physiotherapy modalities (EMS, US, Iontophoresis)
  • Topicals (Traumeel, DMSO, Biofreeze)
  • Training modification

Plantar Fasciitis
  • Microtears and microruptures of the thick
    fibrous band of connective tissue originating _at_
    bottom surface of calcaneous and extending along
    sole of foot toward toes
  • Symptoms
  • Pain _at_ underside of heel
  • Pain is most intense with first steps of day
  • Painful dorsi-flexion
  • Tight calf muscles
  • Most likely 40-60yrs. WomengtMen (Prevent!)

Plantar Fasciitis
  • Causes
  • Pronation and/or Supination
  • Tight Soleus and Gastrocnemius
  • Faulty Foot/Ankle biomechanics
  • Prolonged shoe wear
  • Road pitch
  • Speed/Track training
  • Excessive mileage or training intensity
  • Improper training cycle pattern
  • Age!

Plantar Fasciitis
  • Management
  • Diff. Diag. MRI, Diagnostic Ultrasound and
    examination (dorsiflexion of foot, ankle and
    great toe while knee is extended)
  • R/O Metatarsalgia, Heel Spur
  • Orthotics cast
  • Kinesiotape
  • Myofascial release _at_ Calf group
  • Stretching of both calf muscles and Achilles
  • Rolling TX with cylindrical device, tennis ball
  • Manipulation of foot/ankle/knee/hip/pelvis for
    ROM and alignment
  • Ultrasound tx.
  • Hot Water Immersion
  • Radio Frequency Ablation (Extracorporeal
    shockwave therapy)??
  • PRP

Medial Tibial Stress Syndrome
  • Shin Splints
  • Periosteal inflammation due to overuse and
    pulling of the muscle from its muscle/tendon
  • Symptoms
  • Pain _at_ inside/back of Tibia
  • Dull Ache progressing to sharp
  • Pain starts with activity, reduces then increases
    again at or near end of activity
  • Swollen lower leg
  • Redness
  • Lump and/or bump _at_ lower leg
  • Pain with ankle/foot/toe plantar flexion

Medial Tibial Stress Syndrome
  • Causes
  • Increase in training intensity and/or mileage
  • Running down-hill
  • Uneven running surfaces and road pitch
  • Weak dorsiflexors and/or stronger plantars
  • Over-pronation
  • Inadequate calcium intake
  • Compensation
  • Shoe fatigue

Medial Tibial Stress Syndrome
  • Management
  • Kinesiotaping and Compression Hose
  • Orthotics cast
  • Manipulation/Mobil. Of Foot, Ankle, Knee, Hip and
  • Clear out imbalances _at_ External rotators of hip,
    Hip Flexors (Psoas), and Adductors
  • Reduce volume and cross train
  • Nutritional Anti-Inflammatory protocol
  • Topicals Traumeel DMSO Biofreeze
  • Iontophoresis

Meniscal Tears
  • Meniscus Rubbery C-Shaped disc of cartilage
    attaching to the tibia that act as shock
  • Symptoms
  • Painful Pop
  • Gradual stiffness ensues
  • Gradual swelling ensues
  • Catching or Locking
  • Giving Way feeling occurs
  • Loss of ROM

Meniscal Tears
  • Causes
  • Squatting
  • Twisting Knee
  • Degenerative changes
  • Age
  • Biomechanical Imbalances
  • Repetitive Stress

Meniscal Tears
  • Management
  • R/O degree of tear (minor, moderate, severe) via
  • Kinesiotape
  • Physiotherapy modalities (EMS, Iontophoresis)
  • Biomechanical adjustments _at_ kinetic chain
  • Orthotics
  • Strengthen Quadriceps
  • Training modification (pool)
  • Nutritional anti-inflammatory protocol
  • Nutritional connective tissue protocol
  • HA, Orthovisc, Cortisone injections??
  • TIME

Adrenal Fatigue
  • Stress whether physical, emotional or chemical
    exhibits a response that stimulates the release
    of catecholamines (hormones) and taxes the
    endocrine system (H, P, T, A)
  • The severity and longevity of the stress response
    as well as the adaptive capacity of the person
    will determine the resultant affects!!

Adrenal Fatigue
  • Symptoms
  • Fatigue!
  • Blood Sugar Fluctuations
  • gtBP and gtHR
  • Depressed Immunity
  • Increased fat storage
  • Depression (decreases Serotonin)
  • Elevated cortisol levels promote Inflammation
  • Altered sleep quality despite exhaustion
  • Tight muscles and aching joints

Adrenal Fatigue
  • Causes
  • STRESS!!!
  • Lifestyle (exercise, nutrition, work and sleep
  • Environmental (exposure, chemicals, toxins)
  • Worry, guilt, frustration, anxiety, depression
  • GI disturbances, CVD, Chronic pain, etc.

Adrenal Fatigue
  • The story is complicated, the intervention is
    simple. Jeff Bland
  • Diagnosis
  • Adrenal Fatigue Signs and Self Tests
  • Health history, clinical evaluation, applied
    kinesiology assessment, dietary assessment
  • Lab work biomarkers for stress, fatigue, etc.
    (CBC w/Diff, CMP, ANA, CRP, HgbA1C, Vit D, Vit
    B12, Thyroid, EBV, Lyme, 24 hour urinary cortisol
  • ASI and/or Neuro-Endocrine Comprehensive panel
    salivary/urine - precise measuring of adrenal
    hormone status

Adrenal Fatigue
  • Management
  • Nutrition
  • Consume whole, fresh, organic foods
  • Eat small frequent meals
  • Identify and Address food allergies
  • Sleep hygiene (Neuro-sleep panel for def.)
  • Adaptogens!! (Tulsi, Rhodiola, Ginseng,
    Cordyceps, Shisandra, etc.)
  • Glandular extract adrenal
  • Amino Acids - L-Tyrosine, L-Taurine, L-Theanine
  • Inositol, GABA, DHEA, Pregnenolone
  • Vitamins - gt B5, B6, C
  • Support as needed based on labs, upstream

Degenerative Disc/ Joint Disease
  • Gradual breakdown of joint substances such as
    cartilage, hyalgin, proteoglycans etc. The loss
    of these critical tissues deplete the joints and
    musculo-skeletal system with much needed support,
    cushion and lubrication!!
  • DDD and DJD can lead to pain and significant
    mal-adapted compensatory patterns
  • DDD and DJD generate inflammation
  • DDD and DJD create loss of ROM and over-activate
    adjoining muscles

  • Causes
  • Age
  • Repetitive Stress and Over-use
  • Excessive loads/Resistance training
  • Excessive body weight
  • Biomechanical and Structural imbalances!
  • Deficient nutrition (Omega 3s, Bioflavonoids,
    Silica, Manganese, Vitamin C, Amino Acids)
  • Inactivity, prolonged postures (sitting/standing)
  • Poor intersegmental joint function (Jt. Play)

  • Symptoms
  • Joint Pain Sharp and/or Ache
  • Referred Pain Primary and Secondary
  • Mechano-receptor pain
  • Loss and Painful ROM
  • Swelling and localized inflammation
  • Crepitous
  • Excessive Stiffness
  • Frequently pain lessens with activity

  • Management
  • Diff. Diagnosis with X-Ray, CT and/or MRI
  • Perform Wt. Bearing imaging to assess for
    biomechanical causes!! (MRI, X-Ray)
  • Aggressive physiotherapy (EMS, US, Iontophoresis,
  • Aqua therapy Exercise and Epsom Salts baths
  • Anti-inflammatory nutritional protocol!!!
  • Joint integrity nutritional protocol!!!
  • Avoidance of pro-inflammatory mediators (Grains,
  • Joint mobilization/Manipulation at and adjacent
    joints (ROM and Align)
  • CV exercise with Joint Friendly movements (Erg,
    Bike, Swim, etc.)
  • Orthopedic Intervention - Surgery or
    Hyalgin/Orthovisc when applicable
  • Spinal Decompression
  • Orthotics
  • Brace and Compression
  • Topicals!!
  • Myofascial Release and Foam Roller to ease Joint

Lowe Extremity Stress Fractures
  • Partial Fracture in bone caused by repetitive
    loading. Usually an acute onset/mechanism of
    injury but may be unaware due to gradual nature.
    Can progress to acute fracture.

Lower Extremity Stress Fracture
  • Symptoms
  • Acute onset pain after long training session
  • Pt. tenderness over FX site
  • Pain dec. with rest and inc. with activity
  • Aching and Throbbing late at night at rest
  • Swelling, Heat and Radiating over FX site

Lower Extremity Stress Fracture
  • Causes and Characteristics
  • Non-Critical Heal well and full return to sport
    after 6-8 weeks or relative rest
  • Critical Non-union of bone after 6-8 weeks
  • Due to poor blood supply (Ant. Tibia and Distal
    Tibia (Malleolus) slow healing
  • Increase in training mileage/intensity
  • Non-cycling of training surfaces
  • Poor Shoe dynamics or over-wearing
  • Poor Heel Posting
  • No Metatarsal Support
  • Pronation
  • Biomechanical imbalances
  • Gait imbalances
  • Inadequate osseous nutrition
  • Inadequate strength training

Lower Extremity Stress Fracture
  • Management
  • Diff. Diag. X-Ray inadequate! MRI , Bone Scan!!
  • 6-8 week Relative Rest in non-critical FX.
    (H20, Alt. CV work)
  • Aggressive Bone Nutrition Vitamin D3 (5K) IU, K2
    (45mcg), MCHC (2Kmg), Ca (500), Mg (250mg),
    Choline Stabilized Orthosilicilic Acid (Silicon)
    (3mg), Horsetail (10ml)
  • Increase Dark Green Veggies, Cruciferous!!
  • EMS, Iontophoresis
  • Orthotics
  • Correct Biomechanical Distortion Patterns
  • Kinesiotape!, Compression hose
  • Brace/Cast/Boot and Ortho eval. in critical
    stress fxs.
  • F/U with Gait Assessment
  • Revisit appropriate shoe design
  • Strength training

Rotator Cuff Tendonopathy
  • In response to physical training demands, the RC
    Tendons increase in diameter and thickness
    consequently tensile strength
  • Excessive training or poor technique leads to
    significant collagen synthesis (Type 3) rather
    than functional Type 2.

Rotator Cuff Tendonopathy
  • Symptoms/Mechanism
  • Elevated pain sensitivity due to increased
    development of nerve and blood vessels
  • This leads to degenerative changes
  • Weaken Tendons
  • Leads to Impingement Syndromes
  • Adjacent Bursa inflames!
  • Pain in front of shoulder (Aches!!)
  • Pain radiates down arm but not below elbow
  • Pain increases at night and if lying on
  • affected side
  • Painful arc movement up or down
  • Short Pectorals and anterior shoulders!!
  • Intrinsic shoulder/RC muscle weakness
  • Scapula rhythm altered!
  • Inadequate extension emphasis

Rotator Cuff Tendonopathy
  • Management
  • Diff. Diag. MRI, Clinical Examination
  • Physiotherapy (EMS, US/Phonophoresis,
  • Dry Needle Therapy
  • Myofascial Release Tx.
  • Manipulation/Mobilization _at_ Shoulder spine
  • Aggressive Nutritional Anti-inflammatory protocol
  • Aggressive Connective Tissue Protocol
  • Topicals!
  • Kinetic Rehabilitation - RC isolation with
    progressive resistance (tubing), Pendulum,
    Shoulder retraction/extension based movements,
    scapula rhythm
  • Open shoulder girdle and pectorals
  • Evaluate swimming form, weight training
  • Avoidance of overhead and push movements
  • Orthopedic Eval. (Cortisone and/or decompression
    in difficult cases)