The bench presser’s shoulder

The bench presser’s shoulder

a.k.a Insertional Tendinopathy of the Pectoralis Minor Muscle

 
We commonly hear about a number of sports injuries that involve the term tendinitis. However, as practitioners we often forget a form of injury which presents very similar to tendinopathies. Enthesopathies or insertional tendinopathies indicate pathology of the small part of tissue which conjoins the bone and the tendon. This type of injury usually takes much longer to heal due to the lack of blood supply.

           

            Commonly enthesopathies will occur in athletes due to overuse. I have heard of insertional tendinopathies in the hamstrings and the Achilles tendon but never in the Pectoralis Minor muscle. To my knowledge this is the only study of its kind on the topic. 

Pectoralis Minor

            Overuse of the Pectoralis Minor muscle is common in sporting and training activities. Swimming, pushups and bench pressing can all heavily incorporate the Pectoralis Minor muscle. Injury can occur due to training errors, poor technique, rapid increase in training load, frequency or duration.

            This study looked at seven subjects who reported an increase in their bench press and sporting activity. The duration of the subject’s pain ranged from 1.5 weeks to 9 months. 

Examination

There are only a few key examination findings for a practitioner to diagnose “Bench Presser’s Shoulder”.

            1) Tenderness when palpating the Pectoralis Minor muscle. Palpation must be performed medial to the coracoids process along the inferior–medial orientation of the muscle fibers. This was positive in all seven subjects.

            2) Muscle testing of the Pectoralis Minor muscle will be aggravating. Subjects were tested while lying supine. The examiner then applies a downward force towards the table over the anterior aspect of the shoulder. The patient attempts to thrust the shoulder forward against the pressure applied by the examiner (positive 5/7).

            3) A provocative test was performed simulating a bench press maneuver. The patient is lying supine with both shoulders abducted and elbows flexed to 90 degrees. The patient then exerts an upward force against resistance (positive 6/7).

Treatment

            The only treatment performed was corticosteroid injections into the pectoralis minor insertional tendon, relative rest of aggravating activity with gradual return to play. Pectoralis minor stretching was also prescribed with no frequency given. All subjects were back to preinjury activity level within 12 weeks. Images and references of stretches given are provided. Dr. Wayne Button BSc DC

Bhatia DN, de Beer JF, van Rooyen KS, Lam F, & du Toit DF (2007). The "bench-presser's shoulder": an overuse insertional tendinopathy of the pectoralis minor muscle. British journal of sports medicine, 41 (8) PMID: 17138640
Borstad, J., & Ludewig, P. (2006). Comparison of three stretches for the pectoralis minor muscle Journal of Shoulder and Elbow Surgery, 15 (3), 324-330 DOI: 10.1016/j.jse.2005.08.011

Chiropractor myth #2` (3-5 to come)

If I see a chiropractor I have to see one for the rest of my life.

     I was meeting with a friend a while back and she was telling me about her back problem. She said “I should come see you it’s really bothering me.” “Sure” I replied. Then I seen hesitation on her face and she said “I am worried though....I don’t want to have to get my spine realigned for the rest of my life.” I started to laugh until I quickly realized she was serious. My friend was actually under some misinformed information that when you go see a chiropractor you have to see one for the rest of your life.


        Before I continue I have to let it be known every single patient and every single chiropractor is different. The specialty and philosophy of professionals differ all the time. It’s important as a patient you realize the difference between being pressured to do something and being strongly informed on what’s the best for your well being.

       Sometimes patients forget they hold the power and option to get a second opinion. However, sometimes this is difficult considering the long wait to see a specialist or surgeon. The beauty of conservative health care though is the quickness of a second opinion.  I ask patients to exercise this right all the time. In fact, I am not even offended if a patient visits another chiropractor to get a second opinion based on my diagnosis.  After all I don’t know everything. Few alternative health care professionals refer to one another and I think this is a shame. I know chiropractors that have a specialty in certain injuries, sports and even certain body areas. Why would I not send my patient to one of these people for assistance? Furthermore, maybe this other chiropractor has access to certain modalities or is trained in techniques which better fit the needs of this patient.

         You do not HAVE to see your chiropractor for the rest of your life. You never HAVE to do anything. You have the right to a second opinion and to be informed of your alternatives in treatment. If a patient may benefit from surgery it’s my professional obligation to let them know of this option or at least instruct them to seek out a surgical consult.I have patients that come once and some that are frequent visitors. A patient’s treatment plan may differ depending on their injury, their goals or even their availability. Let’s look at some examples     

     

     The one time only patient can often be one whose injury is not within my professional scope. For example a patient which discovers they have cancer. This is not within my scope of practice and this person needs an oncologist or another health professional. Another one time visit can be those just wanting a second opinion. These patients are often the best patients. They respect your opinion and are really just concerned they may have something serious. Sometimes reassurance is all these patients need.  

           Another scenario is the patient that is a frequent visitor. This patient can be an athlete that keeps getting bumps and bruises along the way. This is fairly reasonable considering all professional sport teams have a full time health care staff.  Another example may be an expecting mother whose body is experiencing pains she has never felt before. Other examples include those with an occupation which creates chronic postural problems.

            One more scenario which I have not dealt a great deal with but have seen before is those people with lifelong disabilities. Some people who have conditions such as multiple sclerosis, scoliosis, cerebral palsy, arthritis, neurological conditions or post surgery issues. Often these patients may report great results with continuous visits to their local chiropractor. They may have consistent pain, need long term rehabilitation, balance training or just simply attempt to prevent their symptoms from worsening.

            So as you can see there are many different scenarios in the average chiropractic office. It’s important to ask yourself what are your goals and more importantly communicate them with your chiropractor. Do you just want the pain to go away, do you want to make sure this never happens again, do you want to get muscle work on chronic problems or do you just want a second opinion. Remember no matter what the reason always assess your options, ask questions and be proactive. After all...it’s your body. Dr. Wayne Button BSc DC  Chiropractor Myth # 1 Myth # 3

Low Back Pain: Where Exactly Is The Pain Coming From?

Low Back Pain: Where Exactly Is The Pain Coming From?

Inspired by the opinions of Nikolai Bogduk & Charles April

     Often through school we are thought to render a diagnosis. We memorize the signs and symptoms and collaborate methods of treatment. This conundrum continues on and on in the academic system only to leave us just as adequate as those which have thought us. It’s easy to fall into this spiral and often at times forget to challenge yourself or the opinions of others.

     Let’s stop for a minute and think what do we know about back pain? The list of causes can go on and on such as a herniated disc, arthritis or even spondylolisthesis. Maybe there are other culprits such as trigger points, infections and even forms of cancer.

     We have now taken things and put them in a nice categorical term. Patients have something to search for when they go home on the internet and insurance companies can make their claims. However, how often do we probe deeper and forget to trace back to what caused the pain in the first place.

     If we don’t attempt to understand the origin of pain in the low back we will merely stay at a plateau and not progress as a profession. The key to understanding diagnosis is breaking things down to the specific structure that is causing the pain. No spectrum of symptoms lumped into a group can always answer this question. We merely need to rely on anatomy, histology, chemical processes and pain right down to the cellular level. Not easy is it..?

     Bogduk & April being experts in studying pain explore this idea. A list of criteria can be met in order to answer your question.

1. Could it be a source of back pain?

     Basically is it actually feasible that a structure can generate pain. To answer this question you have to know does it have a nociceptive nerve supply. Before the 1980’s the disc was not rendered a source of back pain. It wasn’t until studies started to show its nerve supply that the idea of discogenic pain started to evolve. Now studies are looking more thoroughly into discogenic pain (2,3,4). Anatomical studies have rendered muscles, ligaments, vertebrae, synovial joints, intervertebral disc and even fascia as structures with a nociceptive nerve supply.

2. Can it be a source of back pain?

     Just because it’s possible for me to run a marathon doesn’t mean I will. Ok stupid analogy but although structures have the capability to produce pain doesn’t mean they will. After all there is no correlation to degenerative disc disease found on a radiograph and the amount of pain experienced by the patient. Furthermore, finding a pars defect to indicate spondylolysis doesn’t always mean it’s what causes the patients pain. Therefore the structure has to be shown to produce pain in a normal non-symptomatic person in order to fulfill this second criterion.

3. Is it ever a cause of back pain?


     To understand this question you have to look at things in an epidemiological manner. Think of something you diagnosed a patient with that had low back pain. Now ask yourself..is it possible for an asymptomatic patient to have this problem?? Can a non symptomatic patient have degenerative disc disease or spondylolisthesis?? The answer is yes.

4. Is it ever a source of back pain?

     Bogduk & April discuss how pain cannot be seen, cannot be photographed and is subjective. Back pain is barley a lethal cause of death so we never really explore it at the microscopic and molecular level.
Consider that we are often left with forms of imaging that look at macroscopic pathologies. Although, we see degenerative disc disease on an xray it doesn’t show things on the cellular level. It may be that we just have to take this diagnosis and look at it more microscopically to see it as a source of pain. Even if a spondylolysis is evident on radiographs we order a SPECT after to see if the pars defect is active or inactive.

     Their opinion is with the use of diagnostic blocking and provocation discography the essence of pain can be explored. However, this form of diagnosis is hard to come by and can be extremely painful. So although we may not have such tools in our office these forms of diagnosing are helping to set the foundation of where pain is coming from. So the next time someone comes in to you with a problem and asks you “Doctor where is the pain coming from”..go ahead try to answer them.

1. Rehabilitation of the Spine: A Practitioner’s Manual 2ed. The Sources of Back Pain: Nikolai Bogduk & Charles April (Chapter). Craig Liebenson (Book). 2007

2. Does Diskogenic Low Back Pain and Leg Pain Exist without Nerve Root Entrapment? David L. Spencer. Approaches to Chronic Pain 1998;67-71

Hurri, H., & Karppinen, J. (2004). Discogenic pain Pain, 112 (3), 225-228 DOI: 10.1016/j.pain.2004.08.016