Shoulder Labrum Tears: What Clicking, MRIs and Rehab Really Mean

Hey guys, it's Sebastian. Before we start up here, I want to do a real quick announcement for all the DCs and PTs who listen frequently in California where I'm at. I'm really excited to announce that I'm going to have my very first workshop. And this was proposed to me. Actually, it wasn't my original idea, but it's going to happen. So it's June 8th and 9th in Huntington Beach in my very own clinic. And if you've read my book already, I will beat back pain. You'll know at some point I asked a colleague after a few beers, I said, Hey, bruh, what percentage about low back pain do you think you know that I don't know?

And he openly said 15%. I only know 15% of what he knows. That's what he said. And so he claimed he didn't say that, but that's the thing. That's what he, I think that's what he said. And so that opened Pandora's box mainly of curiosity to me. I'm like, Hmm, what is this stuff that he thinks he knows that I don't know? So allow me to do the same for you. And this workshop will literally blow your damn mind. If you haven't been to some of the workshops that I already have too. So I'll even cook for you, honestly. And I'm looking forward to actually making a couple tomahawk steaks, the locally world famous tomahawk steaks that I've been making that you've seen all over Instagram.

So email me info at p2sportscare.com for details. There's not a lot of spots. My clinic's not huge. So rush, get your spot and I'll see you guys there. How many times do you see people do the actual active pull-up and they let gravity just swing them into like a, like a arms ripping the arms off a chicken thing. There's no tension there, right? And how about you be able to buffer that thing a little bit? What if I were to tell you to push the bar away now, now, you know, halfway down, I haven't done that to anybody, but I have told them to be human punching bags. At any point, if I can slap them in the belly and it goes through their guts, then they've lost tension. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now your host, Dr. Sebastian Gonzales. Hey guys, it's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. Now, if this is your first time, welcome. Thanks for joining the hour with me, or this might be an accelerated one actually today. What we're going to go over today is kind of conversations about the labrum, the shoulder labrum specifically. And someone brought to my attention that actually haven't really covered any labrum-based topics. We've kind of hit it here and there amongst conversation with Brett Winchester. We did speak about it a little bit in regards to throwing sports. I did speak about it a little bit with Richard Ulm. I think he was around episode maybe 62, 61, something like that.

But I think what I wanted to do today was actually dive into more patient-friendly conversation and kind of explore the way that I tend to explain shoulder-based conditions, especially labrums, to people. And if you're a clinician, I want you to stick around for this because patient communication is really important. And if you're a patient, hopefully you are listening to this and you're thinking, hey, you know, labrums really aren't that scary sometimes, you know? And before, if you guys haven't already been through this podcast before, I want you to realize the format. The format is foremost, I try to blend the line between clinician and patient and kind of get everyone to have a nice, chummy time and listen to all the non-threatening ways of explaining things and really getting people bought into the idea of actually going and getting something done and actually improving the process.

So, um, I'm always of the thought that I think people are extremely resilient. The body is resilient. The mind is resilient, but at the same time, the mind is the most defeating part of this whole process. Sometimes people want to, they want to understand what's going on, or sometimes they say they want to understand what's going on, but sometimes they don't, you know, sometimes they just want to trust and they want to trust that the process is, is, is not going to be risky. And I totally understand that. So another part of the format of this, this podcast is I tend to go through a little bit about myself, not in a selfish narcissistic way, but I, I, I'm attempting to reveal parts of myself so you guys can understand who your host is. So I'm going to go through a little story here in a second to let you see into my world a little bit. Now, a little housekeeping is, um, and I think this will span a little bit over to the patients as well, but I did write a book about low back, uh, my experience with low back pain. And although it's not about shoulders, it's about the experience of mainly being a patient and not completely being on board with a treatment planned and having questions and, and wondering really about, uh, if you're ever going to get better or not. And so with this book, this book is called, I will beat back pain. It's based upon the cool runnings movie.

Yul Brunner tells Junior in the mid to say, Hey, I see pride. I see power. I see a bad-ass mother who don't take no crap out of nobody, you know, and then goes on there and starts a bar fight. So I will beat back pain is mainly telling yourself that you will beat back pain. And if you're a shoulder case, you're going to say, I will beat shoulder pain. And so that whole book, if you're interested in it is on Amazon, you can go onto my site, p2sportscare.com and it will take you through the Amazon link. There's audible, there's Kindle, there's print book. Um, but it takes you through all of the, um, necessary mental parts before you start actual recovery. There's, there's no physical recovery suggestions in there. It's all a mental preparatory thing before we actually get into recovering. So before we start, let's get into the, uh, little bit here and we'll start into the content on shoulders. Now I know I've talked about textures and foods before where in and out just blatantly just doesn't seem to care about texture. Everything's just soggy, but the habit, you know, on the other hand, they got this crunch. You can't tell if you can hear it or feel it faster. You can't tell, but you appreciate it. You appreciate it. It's kind of like having crunchy versus soggy fries. Like it just, no one likes a good soggy fry. So I think though, another thing in life that you could easily get a good contrast on and start to appreciate what one side is feeling, not the other is a jacuzzi in the rain. I don't know if anyone's ever done this before. Like you do it in torrential downpour, the jacuzzi is just smoking and then it's a cold rain. So then you can feel just like just enough. Like you kind of bob up and down, like just so you have enough up and enough down to really get the good temperature change. But the contrast is the amazing thing. I'm all, I'm all about contrast. It's like, you can't just wear black. Like, I don't know why people just wear black on top. They wear black pants and black shoes. And they're like, yeah, I'm stylish. You know, like, I don't think that should be a thing. I remember people in high school wearing these black on black outfits and it didn't make any sense to me. So all of a sudden though, like imagine like you had those, those jammers or like those sweatpants, you had blue sweatpants and a blue shirt. And also someone called you grimace, you know, all of a sudden that doesn't work. Why does black on black work? Right. You need a little contrast with everything. So the jacuzzi, if you're looking for real life contrast, do it in the rain. I think you'd be surprised. Okay. So I'm going to go through the basics of how I kind of interact with a patient in their first time with a shoulder exam.

And they might have a concern about a labrum or a rotator cuff or whatever it might be, but I'll try to slip into my, uh, my mode of actually talking to a patient. Cause it's funny how, you know, I'm not speaking to anybody right now, like physically, no one's here. I'm speaking to a wall with corrugated, uh, little ripples on it, black little ripples in the closet. That is my studio in my office. So it's sometimes a little bit hard to slip into character here, but I'll do my very best. And, uh, I always tend to think I'm, I'm better when there's two to three people in the room because I always, uh, tend to, uh, I can play off them a little bit. And, uh, instead I'm going to have to go off the top of my head here. So in my experience, people come in with these shoulder conditions or shoulder conditions in general, thinking that something is broken or torn.

Okay. So I tend to think about what they're thinking about and try to address their concerns. And so a lot of people have heard maybe that their labrum could be torn or that they have a rotator cuff tear or that they have a inflamed bursa in their shoulder, or that the biceps tendon is swollen and overused. Whatever they might be thinking, I tend to think it's our responsibility as clinicians to address their concerns. So I tend to ask people, what, what do you think what's going on first after they've explained their story? And by the way, if there's any numbness tingling involved and I tend to ask about the hands or neck tightness, um, changes, sensation, past injuries and things of that nature, because I think a lot of times that, especially with the numbness and tingling, they, um, they, they tend to think it's not always correlated. And so they don't always address it and like, Oh, I do always wake up with that hand being numb. So, uh, there is another, uh, I think it's one of three. If I had to recall, there's one that I did about a shoulder, shoulder pain, extremity pain based upon cervical based pathology, uh, disc or nerves. So I think that's an important one to follow up with if you guys are listening to this. So if there's numbness, tingling, a little bit of burning, dull ache down in the forearm to the fingers, I think those are concerns that you should be looking at nerve based considerations. Not that the nerve is torn up or anything. It might just be a little pressurized is all. Um, but consider that. So when I do, do go through the examination, I tend to ask people that a lot, but also too, I like to ask them what they think is going on. And it's always interesting to hear their stories. And, uh, I've, I've made it a attempt over the last probably six to eight months now to spend some time actually on the phone with people that I don't know and just ask them what they think is going on and what their fears are with this stuff. And it's always interesting to hear their words. And it really helps me write articles surrounding the topics because we have a tendency as, as clinicians to be very, uh, technical and it doesn't need to be that technical. We just have to get our information across. So a lot of times people will think that their concern, well, their concern is that they have a swollen tendon or that the tendon will become ruptured if they throw a baseball or if they crawl around on the ground or if they do jujitsu. And with labrums, a lot of times they're, they've kind of fallen into that category of being worried about labrum because they hear a clicking or popping going on. And this is actually a whole tangent conversation, but I have, I've had a lot of people come in where they're like, well, there's a popping going on there. I said, okay, is the popping your symptom? Is the popping why you're in here? And they said, no, well, it just seems to pop. I said, well, does the other side pop? And they say, yeah, the other side pops. I said, are either from painful when they pop? And they say, no. And so I, I just reassure them that the, the popping and clicking sometimes is, is normal occurrence. You know, things are moving around in there. It's, it's not always that there's anything wrong. There could be, you know, but, um, for the most part, it might just be a normal occurrence. So I think we need to separate the difference between clicking and popping it and pain or the symptom or whatever reason they, they presented into the office. Um, I guess another side tangent conversation based upon clicking or popping. Um, someone came to my office recently and they said that it was just a random side thought. They say, Hey, this, this shoulder's popping here. What do you think? I'm like, I, I don't know. Like we're not doing a big old exam on it, but you know, when, you know, and they would reach their arm up to the side and overhead and stuff. They said, Oh, clicks and pops kind of like this. I said, is it painful? And they said, no. I said, uh, is there anything wrong with that shoulder? They said, no. And they said, well, they have a lot, a lack of range there. So I hadn't, I hadn't do it on the ground on their back because they were doing it seated or standing and they were able to do it in the ground on their back and it was reduced. And I said, well, what'd you learn there? And they said, well, I, I'm not sure. And I said, well, it's, um, whatever is happening is based upon maybe gravity or posture or position, you know, because you would think if something's torn up in there, it would do it in the other position too. Right. And so we, we loaded the shoulder blade a little bit in regards to, uh, kind of biasing the movements to getting the other ones of the shoulder girdle working with the ones that I thought that were important in question there. And then they, he stood up and he's like, Oh yeah, the clicking's a way reduced. So in that case, maybe the, the clicking was a sign of something going on, you know, since, especially since he had lower range of motion that side, but I think learning what people are, are concerned about is really important and what they think is going on as well. So a lot of times they'll say, well, I think I have a tight pec minor, or I think I have a tight upper trap, or I think that this is an old shoulder injury from baseball years ago that I, I'm not quite sure convinced this is going to go away. Or maybe they saw another healthcare provider who told them that, well, you're not going to be able to throw a baseball anymore. Um, and this shoulder is probably going to hurt for a while and you might need it surgically repaired to breathe later. So there's a lot of these, uh, biases going on in their head. And I think they're all merited. And I say, look, those are, those are very good points. And I will take them into consideration when we look at things through here. But, um, as we know, there's a lot of other, uh, there's a lot of the reasons for maybe tightness of muscles. Maybe there's maladapted movements. There's movement compensation. Maybe there's neurological based tightness or guarding going on, you know? So there's a lot of considerations there, but what they believe is, is truly important because it helps us navigate what we're going to do with this person. Um, now considering that they might've been told that they can't use the shoulder really well anymore, or if they've mentioned that they're not sure it's ever going to get better a hundred percent, I think it's an interesting bridge to cross. And that's actually why I wrote a book kind of like how he did for the back stuff.

And I reassure him that based upon what I find, I think that I tell him the body's very resilient, you know, and I think that we are capable of improving more than we think. And so if, are they, are they married to that idea or are they, are they open to the idea that, that they might actually be able to do what they want to do again? And sometimes the, the response is, no, I'm pretty sure this, I just want to do, be able to reach up above the fridge and, and, uh, throw away a box of cereal. I don't know who, who eats cereal anymore anyways. So maybe they just want to do that. And that's fine. That's totally up to them. Maybe they want to throw a baseball again. You know, I'm not the one that should really decide it for them. It's really based upon them.

But if their goal is to be able to throw a baseball, I think I can get them to play second base probably. So next, I like to ask them what they think will help. And sometimes they'll say, well, I think stretching will help. Sometimes they'll say, I don't know what will help. That's why I'm here. Um, some people will have read a lot of information on the internet and they'll tend to think that maybe some tissue work will help, but also too, they're probably going to end up having surgery. So these are very interesting questions because I think if I think back on, on what I did with some people, it's different than what I would have done with others. And I still do remember this knee case that I had. It's probably one of the default stories where I think that I did a really poor job of really understanding what the person was asking for. And so they came in with knee-based pain, um, both knees. And I think, I think, uh, anyways, they had pain with squatting.

And so I cued them into a little bit of a, uh, hip external rotation with, or cuing the glutes to work a little bit more squatting and put in hinging her instead of, instead of shimming her straight down. And, uh, her knee pain went away. And so I followed that route a little bit and we spent a bit of time doing some hip-based work as well as patterning of the squat, um, via the hinge first. And at the very end, she's like, when are we going to do something for my knees? And I told her, we, we are, we, we did. How do you, like, you don't have any pain with squatting anymore. But what she originally came in saying was that she felt that tissue work would help her. And I'm not saying tissue work was the wrong thing. I just found something that was working a little bit quicker. And it's something that, that I was a little bit more married to the idea of doing. And so, uh, I didn't quite explain that to her in the beginning and I just kind of progressed down the route. Now going into what, what I, what they think will help and what I think will help is, uh, it's, it's important to obviously get them to leave feeling better. But if they are married to the idea of something, it's kind of my responsibility to, um, do a little bit of that enough to make them happy. Cause I need them, I need them to come back to, to do more of what I think. And, and I know will help them. And a lot of times I'll have the, uh, the conversation about structural damage versus biomechanical loading.

And, uh, I take this out of the McGill book a little bit when he's talking about butter, but at the same time I've, uh, I've used it with, uh, random objects in the office and I hand it to him and say, look, here's my cup of coffee right here. You know, like hopefully in the morning, if they're a morning person, then it's probably full, you know, so it weighs probably a, I guess, a couple of pounds cause it's a Yeti, it's a taller Yeti. And, um, so they, they, they hold it and I said, good, hold that right there. We're going to keep talking a bit. And then after a minute or so, they're like, well, this is kind of getting tired. I'm getting tired. Can I put this down? And I try to do it in the hand or, uh, sorry, the arm that is actually not the, the painful one or the one they're in concerned about. Cause they, number one, they probably won't do it in that hand or it'll start to trigger and they'll say, well, yeah, that's my symptom. Then it'll be a tangent conversation again. But I, um, I say, look, we're going to put this thing down now. What do you think's going to happen to your arm?

They say, well, it's going to feel better. Right. And so now there's nothing physically wrong with that shoulder. And a lot of times they're married to the idea of getting an image and x-ray. And that's just a very, it's a very patient based, um, idea. And I have no problem with x-rays or MRIs and arthrograms. I got no problem with those things, but they don't always help me as a clinician guide you better. So what I like to talk to you about in that situation is that there's, there's nothing that will show up on your MRI with this situation here with you putting the cup down. It's just simply unloading a painful structure or offloading, I like to say.

And so I say, look, we can do an image on the, on the other side, but realistically all of the stuff in there is possibly, or all the painful stuff in there is possibly under the same circumstances, it's just not as abrupt or apparent to you. But I think if we start to offload these areas, the symptomatic areas, the, we, we can kind of ask, we can find out what the body's looking for. And the simple thing is actually the cool thing is actually that all these areas that are painful, if we get the body to do what we're wanting it to do, or the, or we're allowing it to offload that area, it will decrease your symptoms by probably half in just a couple minutes. And they're like, sure. Like this, it sounds good, you know? And they're always a little bit hesitant though, with either like, well, don't I need tissue work on this? Don't I need to do this on that?

Don't I need to stretch that? And I'll say, well, there's a time and place for that. And I know that I, so I've spoken with Justin Dean a couple of times on this, Dr. Justin Dean about the idea of that tissue work is kind of like people are starting to get away from it. And he's like, I think that's a bad idea. And I'm like, well, I think it's a bad idea too. And I don't tend to talk about tissue work a lot on here because I think people are already on that boat. Like patients already want it, you know? So I think if we focus a little bit more on talking about it, they're going to be married to the idea. And all of a sudden we become the, the quote unquote fixers, the one with the magic hands, you know? And I think there's a time and place for that stuff that it's not always needed immediately. I tend to go a little bit more towards the movement or loaded base route. So the patient's number one, have a little bit to do at home. Second is that they realize that they're in control of their own destiny. And lastly is that they're not really married to me. You know, they're not, they're not dependent upon me. Like it's a bad business model unless they, they, I, I opened Pandora's box and they, they want it to learn a little bit more of strength conditioning because I can show them that stuff, but they don't always need to come back all the time, you know? And, and I think a lot of times they're, it's a teamwork thing.

They're helping me offload that structure when they're at home and I can help do some manual therapy, uh, with it when, when they're here. So a lot of times getting in figuring out what, what they think is helpful, I think is very helpful in how I make that conversation about loading because loading in my experience with shoulders, it, it helps tremendously, tremendously. Now the one caveat to that is, is that if we have a neuro-based complaint, um, maybe some tingling numbness or, or stuff into the hand, I tend to address the nerve first and I think nervous, the nervous system's the boss. So, um, I think Justin made a good, um, he made it, he made a good, uh, example of this. He said, what happens when a bone breaks? And then we're like, well, it heals. What happens when a, when a muscle tears? We say, well, it heals. What happens when a nerve tears? Well, it, it won't come back, you know? And so there's a hierarchy of protection there. And sometimes the symptoms that they're having in the shoulder, the clicking and popping, the tightness is, is a protective response over the nerve stuff. So we need to be considerate of that. Um, now I tend to ask people what they tried as well with this labrum or the rotator cuff for the clicking and popping. And a lot of times people have tried a lot of things that, that, that, uh, we've, we probably don't need to do again, honestly. Um, they probably tried a lot of stretching, a lot of self tissue work, a lot, a lot of that kind of stuff. And I'm not saying, again, there's not merit for it. It's just that they've already tried it. Why try it again? You know, why, why, why blast it? Like we've already done it. And so I tend to look for the elephant in the room. I'm say, what do I say?

What do you do for, um, strength condition? Do you lift any weights at all? They say, well, I do a lot of pushing, you know, I do bench press, incline press. Um, I do dips, um, things of that nature. And so we see a very top heavy approach there. I'm like, do you have a, do you ever squat? And they say, well, no. Do you ever hinge or deadlift? Well, yeah, I do sometimes. Do you ever carry stuff? No, I don't. Do you ever pull? Yeah, I do pull-ups, you know? And so we're seeing that there's things missing in there. This is kind of based upon those Dan John principles, like the push, pull, carry, uh, push, pull, carry, uh, squat hinge. And I personally found that with various different types of conditions, when you find out which movement is, is the painful one, you kind of do the other two, three of them, four of them, and then you come back and all of a sudden that one's not painful anymore. And a lot of times they'll, the patient will say, well, maybe it warmed up. Maybe, maybe we don't know. No, but, but I tend to think those, the other movements well round, um, the body and it can stabilize itself and offload the structure that we're, we're concerned about. And so I see the elephant in the room. If, if they haven't done, say if they don't do any cardiovascular fitness, you know, I think, and they do, and they do a lot of weight training, a lot of stretching, a lot of yoga. I'm, I think I want to add a little bit of that, you know? And if they do a lot of cardiovascular fitness and a lot of swimming or a lot of triathlons and they do yoga and stretching in the morning and they do, um, you know, a lot of tissue work or self massage, I think, I think we're missing resistance training here.

You know, I think there's, um, I don't, I don't have anything to validate this honestly, but it tends to work a lot. It tends to work a lot. And so I think when you pick the elephant in the room, then, uh, whether they're spending time with mobility or strength training or cardiovascular fitness, I think there's a lot of secondary effects that help in there help within that realm. Let's say cardiovascular fitness. I mean, blood moves around. It helps, it helps, uh, repair areas. You know, how's this a bad thing? They found it that it's helpful with concussions, you know, brain injury people. Um, so I think there's a lot of secondary effects that happen when we, when, when we find the elephant in the room. Next, I like to go into what we're testing actually for. So I go through the whole ream of tests and I tell them, look, you can ask me questioning a question at any point, but if we're looking for, uh, your labrum in question, I'm going to also screen out a bunch of other stuff. And the reason why I address this to them head on is because I want to make sure that when they leave, they feel like everything's been looked at. So they don't need to go somewhere else yet. They don't have, I don't want them to have distrust in what I've done. So I say, look, there's a lot of things that can be, uh, creating this, this symptom pattern for you or this, this presentation for you. Okay. So I'm going to be looking at all the things that it could be. Um, we're going to do all of our orthos neurals for the, for the neck, as well as the nerves coming out of it. We'll look at the shoulder and also some of the joints, uh, blowing around it and also the, the, the mid back. So, um, if you, if you're going to go on home, go home and look for Google, Dr. Google, then you might look up rotator cuff, bursitis, labral tears, uh, nerve impingement, cervical stenosis, um, things of this nature, mobility, stability. You might look at all this stuff. Just know that I've taken all this into consideration when I've examined you. And I'm going to tell you what I think is relevant. That way they can kind of cool their jets a little bit and just kind of feel like they're being taken care of, you know?

Now, based upon what I find, let's, let's just say, cause this is a labrum, I guess, topic. They've jumped around a little bit. Say we're talking about labrum. The way I typically explain labrum is say, I look, there's, there's a couple of tests in there, three tests in particular, the ones that I use that are going to show beyond reasonable doubt that there's something going on with the labrum. And, um, I like to explain it. I get this, uh, I have a spine model and I show the shoulder and I show the, uh, the, the shoulder blade. And I said, between here, there's the, there's an O ring. Okay. It's a gummy little O ring right there. And it actually provides some stable stability for your shoulder to move. And the rough estimation is about 70%. Now, sometimes when the shoulder is not really centralized and, and, um, it's not able to go into the, into the little part of that socket right there really well, it, it tends to irritate the rim.

Okay. And to be considered as well, uh, I, we got to figure out if there's trauma or not. Cause the conversation goes a little bit different with trauma, fallen outstretched hands. Sometimes you have trauma, trauma to the region and actually create a bigger labral issue than, than you think. Um, and there's really not a biomechanical, um, consideration of, of how it happened. But a lot of these ones are non-traumatic and they're quote unquote overuse. So I think when you take into this, we take that into consideration a lot of times where this, this conversation will work very well. So I, I tell them that that, that O ring helps out with deepening the socket.

Cause if you look at that shoulder, there's, it's, it's a unique joint in the body where gravity actually tends to dislodge it, right? It pulls it out of socket all day and the labrum deepens that the other ball socket joint in the body is, is the hip and actually gravity feeds it. Okay. It helps stabilize it. So then I, I tend to point out the areas of the body that stabilize the shoulder girdle because really the shoulder girdle is the one that helps keep gravity kind of as if it were a friend and imagine like a little bit of an upswing of the shoulder blade to kind of make it so the glenoid labrum where the, uh, humoral head sits and forms that shoulder joint, uh, that it's not quite downward sloping or facing the floor. It's kind of in the middle or it's facing outward or a little bit upward. Now this is where gravity tends to have a little bit more of a supporting, um, a supporting chance, you know? And so I explained that the orientation of this joint right here is really based upon the shoulder girdle and how well this joint is oriented will allow it to repair itself better. Okay. And so I tend to point out the dynamic and bony stretch of the shoulder and say, I grabbed this whole shoulder area on them on the model and I show them. And by the way, if you're patients and you don't understand what I'm talking about, look up a shoulder real quick, um, bony, uh, bones of the shoulder and it'll pull right up and you'll see that there's really only one bony attachment for the entire upper quarter for that whole shoulder. That whole shoulder will literally rip itself out of its socket and fall onto the ground. If you didn't have these other areas supporting, there's only one bony attachment. That's the shoulder or the clavicle or the, uh, what do you guys call it? The clavicle or the collarbone. So it's the collarbone is one. The second is a dynamic strut on the backside. And I think of this kind of like a car where you got your, you got your front wheels, you got your little, uh, steering struts and everything. And then you got this other area, which is kind of a mishmash of things.

And so the shoulder girdle is really just floating there attached by musculature. And so the musculature has a profound effect on how well your shoulder functions. Now, can we go down the route of explaining um, the degree of the labral tear and all that jazz and like, yeah, we can, but honestly, we don't, we don't really know yet because, uh, in this case, this, this phantom model, I don't have an, uh, an arthrogram. I don't know. And so I'm basing upon a rough thought based upon the examination. But a lot of times labrums are their rehab cases in my book, unless they're beyond a grade two. Okay. And obviously we can get into much debate about, um, uh, kind of middle range grade two and above. But, um, I think it skews the needle a little bit more towards rehab when we figure out what the person's, um, goal is. Do they want to play a sport again? Do they want to just carry groceries? What's the age of the person? Um, say the person's 70 years old, are we going to really, is it going to be extremely helpful to put them through that type of rehab after a procedure or even the anesthesia sometimes will knock people out, um, their consciousness and their dementia will sometimes be affected. That's my, that's how my grandpa was. Every time you put them in the hospital to do something like his dementia was, got out of control. And when he was not in the hospital, so he's perfectly fine, you know, and it was when he was out the, without the anesthesia, he's perfectly fine. So I think those are all considerations there. And, but if I had someone who's wanting to throw again, maybe that, uh, surgical consultation is going to be a nice thing for them. But also too, in taking this kind of out of the book, uh, when I interviewed Brett Winchester way back in the day, God had to be over a year ago now. Um, he talked about how people, um, players in baseball, when they get to his level in the, uh, major league baseball, all of them had to have how all of them have some degree of shoulder pathology. Like their shoulders don't look perfect. Right. But they can, they can throw a lot of times they have no pain, but a lot of times when they present to your office, they'll have pain. Right. And they will wonder what the heck it is. So now we're on that structure versus by my, my biomechanical loading problem. Cause everyone wonders, well, I'm hurting. What could it be? What is the thing? How do I fix it? It's always the it, you know, and they don't always think of the it as a, uh, as a loading process, the process. And so Brett comes in and he takes, he takes a look at the MRI and he says, look, you got a little bit of fraying here and there and so on. But look, I would trade shoulders with the any day. And it looks based, it looks normal based upon the activity level and the activity you're doing. Okay. I don't see any reason why you can't, can't improve. This is, uh, and we kind of brushed off the side and it's always, we're always treading that line a little bit of, of if we should fully disclose all of the, the nuances about the person's image and about what they have. Uh, and I know they have a responsibility and a, um, we have the responsibility to tell them, and then they have the right to know. But at the same time, when they, when they kind of jump into those images and all the findings in there, they get lost in the results and they get lost in, in, uh, what is actually clinically relevant to them. I had a gentleman that came in, uh, about last year or so where he had, uh, he had some neck pain and it was kind of a slow insidious onset. I was looking for, um, I was looking for sinister pathology, pathology actually. So, um, I did an x-ray and I just wanted to look and I said, look, before, before we look at this, before I send you this, I want you to know I'm looking for one certain thing. Okay. It's going to say a lot of things on there because you're 50, right? There's going to say a lot of things on there, but, uh, if you get the, the image and the report before I do, don't freak out. I will talk to you about the relevant things. And if you don't hear from me immediately, then the things can wait till next time. And we'll talk about it then. Okay. And so the next time he came in, he's a very analytical guy. He said, you're right. I looked at all those things. What are all these things? So we actually talked for 30 minutes about the other things that I think were not relevant in his case. And I told him, look, look, man, I was looking for this specific thing and we didn't find it. We didn't find anything you really need to be concerned about because look, look, you, you had all this stuff in this case, it was arthritis and stenosis and so on.

You had all this stuff, uh, three weeks ago and you didn't have any neck pain, right? He said, yeah. I said, good, cool. It's been there for years. Don't worry too much about it. Let me just show you what to do. And so a lot of times they'll get hooked into this idea and all of a sudden their brain was going to run wild. So with people with shoulder conditions, it's the same. They're going to see a little bit of label for, and they'll see a little bit of bursitis and swelling around the area. They're going to see, um, uh, rotator cuff frame. They're going to see all that kind of stuff, a little bicipital tendonitis. And when patients see that, sometimes they freak.

Okay. Patients, if you listen to this, just know that not all these things are, they're not always relevant. Okay. I remember I had this girl in one time that she had, uh, she had foot pain and she was a runner. She was a, she was a distance runner in college. And, and, and I said, look, I talked to her coach. I said, look, I'm concerned. She has a stress reaction. One of the, in one of the, uh, uh, metacarpals at a tarsals at tarsals. Um, and I said, look, I need to get an MRI to see it, but we might find other things in there. And so lo and behold, it came back and we had, uh, perineal tendonitis. We had Achilles tendonitis. We had tibial tendonitis. We had all these tendonitis is right. That showed up based upon the report.

And it was negative for what I thought, what, what we were looking for, because it would change the course of action, uh, of care. And so she asked, what's all this stuff? And I said, well, does it hurt? And she said, no, we pressed on this boss really firmly. Does it hurt? And she said, no, I said, don't worry about it right now. You know, like we're already kind of rehabbing you to, to offset the risk factor for these things. And so when we're talking about shoulders, it's like, if we're referring out, looking for certain types of findings on an image, all these things are sometimes normal variants or they're normal things based upon your activity. Um, but they're not always painful. It's, it's really important to realize that. And again, through the book that I wrote, I will be back pain. You can find it on Amazon. You can find it on, on my website. Okay.

I've gone through this, uh, with, with everyone extensively. And I had an MRI from when I was 15. I had one when I was 35, they showed the exact same thing, you know, and I had 20 years of pain-free, uh, time of the, of the back during that, during, during that time. And so the finding is not always relevant, if that makes sense. And it's, it's, it's normal to have these, what we call wrinkles on the face of the MRI. Like your, your joint can have some wrinkles and wrinkles don't hurt when they're on your face. So there's signs of things going on. Uh, and they are helpful to the clinician to figure out what they want to do with you, but they're, they're not always, um, they're not always painful. It's just nice to know that if you have wrinkles, maybe we put some sunblock on every once in a while, you know, maybe wear a hat every once in a while. Maybe you don't smile quite so much because wrinkles can do that too. So sometimes those wrinkles are a sign of good things happening, right? So, um, it's always important when we go through that, um, through the examination that we, um, if we have an image in, in play, then we need to make sure we explain it in that fashion, uh, because it can really spiral people. You know, they get very married to these ideas of arthritis and torn this, and I have a bum shoulder and blah, blah, blah. And they're merited, I understand it. I've been there. Okay. But it doesn't help the things that we're going to do.

And I'll take this from, uh, Joe Horgan's, uh, lecture in the diplomate program is that the imaging is intended to, uh, see if we need to change our course of action. If it, if we're looking for stuff that is not necessarily going to change our course of action, then we don't really need to look for it. Um, hope that got it right. That got that right, Dr. Horgan. Um, but for the most part, if you're looking for something that will change your course of action, you need to do the, you need to do the proper imaging. And if the proper imaging that is, um, merited, say an x-ray is not looking for the, actually that'd be say the allowed image. If the, if the image allowed by say an insurance company or whatever is not actually going to see detailed the thing that you're looking for, then get something new. Okay. I remember that he, he shared a story, uh, Dr. Horgan shared a story in the diplomate program where he was looking at someone with a knee condition and two MRIs came back negative. And finally, the third came back positive. Uh, and it was, it was, it was a compression fracture. So it was, it's interesting to see that we can miss those, um, or the image can miss those, but it, but it's, it's, it's nice to know a game plan of what we're looking for. And so patients, if you're listening to this, just stick with a clinician who knows logically what we're, what we're looking to do and jumping around to different clinicians is not always helpful because everyone's starting fresh again, whether they're competent or not, they're, they're meeting you partway in your, in your novel that is you. So you can't always expect them to pick up the pieces in the beginning and be caught up even if you've seen them a couple times. So you need to make sure that you're sticking on board with the person that understands your condition. And if they can't help you, they'll probably refer you on now.

Something else I really like to do for people when they are concerned about a joint is I like to stress test it. Okay. And I've done this with knees and ankles and so on. And everyone's worried about like, well, can I, can I go hit a golf ball? Well, let's, uh, let's see. You worry about your knee. Okay, cool. Let's stress test it. And so we stress test it and valgus and varus and check the ligaments, check the musculature and see if beyond a reasonable doubt, it's going to explode, you know, when someone moves or steps or throws. Um, and if it doesn't look like it, I say, sure, why don't, why don't we, why don't we start in that movement again? Because a lot of times that movement of say, say we're getting this person to throw or lift overhead or whatever it is, we can get them in the position, at least isometrically and just get them to feel, get their, get their subconscious brain to feel that area is not, um, a painful movement. And if it is painful, we don't need, we don't need to press them into it, but it's important to expose the athletes slowly back into the, the movement that they're, they're looking to accomplish. Because if you decondition the athlete to it, then I think we have a larger hill to climb after that. Um, also too, it's important to really look at the person as an entire whole. So patients, if you're, let's just say you're a throwing athlete, say you're right-handed throwing athlete. Did you know that really only, I think it's under 20%, I want to say 18, I'm not sure. I'd have to look at the research on it.

Um, of the power to the ball or to the projectile really comes from your shoulder. So it's not a lot. And so I know it's important for you to look at your shoulder, but at the same time, it's important to look at the other spots that are not doing their job that are loading the shoulder excessively. Okay. Well, some of the areas I like to look at is number one, you look, I like to look at the, the hips. Can they post up on the front side hip as they start to propel the ball forward? Can they balance on a pitcher? Can you balance on your back leg as you're going into your movement? If you can't, then you can't make that wave crashing thing that happens with your mechanics and you're throwing. Also too, are you throwing just, just poorly? Okay. Did you, did you learn to, to pitch from we, you know? So I think going to a pitching coach is important because if you, if you pitch poorly and your mechanics are poor, then we can kind of expect your shoulder hurt anyways, right? Um, core endurance is a nice place to start as well. I can't tell you how many shoulder cases we we've, uh, incorporated some type of core endurance and it's been helpful as well.

So those are all definite considerations that you should have when you're working with throwers. And let's see, where should we go from here? How about we go into, um, tension? Tension is really important with, uh, I teach a lot with rehab and I guess I'll start with the rehab that I do is I have implements in the office and I don't really like to call them weights. I don't like to call them barbells. I don't like to call them kettlebells and dumbbells and med balls. And I, I don't like it mainly because it's, it's just a teaching tool. All right. Some people are scared of, of lifting weights. Some people are, are definitely afraid of it. I'm okay with that, but they have to realize they're in kind of encounter some type of weight and load throughout life anyways. And this is just, uh, helpful in, in navigating that load. And so when we go with shoulders or let's just say positions, um, say we're going to break down the mechanics of, of throwing.

It'd be nice if you can, let's say your right-handed thrower would be nice if you can stand on your right leg and have your left leg up and have your hands at your chest with that pitcher's prayer and just hang there, you know, and make sure there's no slack within the movement. And for all we know, this person is kind of leaning onto their, the, the outer arch of their foot, which kind of makes their knee buckle and makes it to the front side of their, uh, or the inner part of their foot doesn't contact, um, the rubber, or I guess the, uh, I guess that'd be the dirt right there. So being able to find tension and control in these positions as they hit them is going to be important. And so next we can go into our, our lunge, right? Or being able to post up onto the left front side leg and being able to control the tension all the way throughout. And, you know, probably one of the easiest things for me to explain it when it comes to tension or dead spots is that I've been, I've been attempting to use the idea of redlining. I've been explaining redlining to people.

And so one of the typical ways I'll use redlining is when they're, when we're doing goblet squats is because sometimes they'll have hip pain or knee pain with goblet squatting. And so I just tell them, look, I'm going to stop you at a depth that it looks like you're, you're, you still have good tension and you still, you still have the ability to drive up out of the hole and be able to have power. And again, this is not a thing about teaching the squat. It's just about teaching tension. And the, the squat is just a simple one for me right now anyways. And so I'll say, look, I'm going to snap my fingers when I want you to be going up. And if you don't hear me snap my fingers, I want you to make sure that you're monitoring if you still have power to get up. And by the time I snap, you should be turning around now, now, now, now. If there's a lag time, like I snap and they're like, now, then there also probably wasn't appropriate tension in that range. And so they got sloppy. They allowed themselves to drift across the line. All right.

I want them to touch the line and go, touch the line and go. Think about basketball suicides, touch and go. And so they're paying attention to their foot contacts and if they have power overall. Right. And so I tell them, look, we're going to go through these squats right now, and I'm just going to stop you at variable ranges and I want you to power out. Okay. And so I might stop them a quarter of the way up, go. I might stop them halfway, go. And I might creep them deeper, go. And at some point I don't snap. And I say, look, the red line analogy, this is how it comes into play is, you know, like they have cars now that are like, they have paddle shifters. They're like, I call them mock sports cars because really, if you have a sports car, you'd probably have a stick.

And so they have these paddle shifters, right? And they're like, oh, look, you can actually, you can shift your own car. It gives you the illusion. You can shift your own car. But what happens when you actually don't shift and you just gas it? It at some point hits the red line and it shifts itself. So why the hell those things even there? You know? And so, but the cool thing with at least these, uh, this red line thing is it protects the engine and it protects the remainder of the car too, I guess. And so I tell them, look, at some point I'm like, I'm paddle shifting you right now. If you don't hear me shift, I want you to shift yourself.

And you're going to know when to shift when you feel like you're losing the ability to shift quickly. So we bring that back to a shoulder. Let's just say we're talking about someone with shoulder pain with kipping pull-ups, right? How many times do you see people do the actual active pull-up and they let gravity just swing them into like a, like a arms ripping the arms off a chicken thing. There's no tension there, right? And how about you be able to buffer that thing a little bit? What if I were to tell you to push the bar away now, now, you know, halfway down, I haven't done that to anybody, but I have told them to be human punching bags at any point. If I can slap them in the belly and it goes through their guts, then they've lost tension. All right. And I try to slow the movement down for them as well. And so if we're looking at pitchers here or throwers, then their body is turning away. Their torso is turning away from their arm, which is still, it's going to be coming with it.

And if there's tension within that front wall sling or the, uh, I guess, oblique front wall sling and the shoulder girdle itself, then it's going to come with it and it's going to accelerate with the rest of the body. And so if there's no tension there, then they're going to almost rip their arm off. And then the labrum and the rotator cuff and all these other things in the bursa, all of them get really pissed. And that is how we get our things, I think anyways. And so I think teaching tension can be, you can do this in a very, uh, varying different ways to people. Um, I like to use the floor and if you've done DNS, um, or some seen some of the DNS exercises, some of those ones are useful for creating tension. Sometimes something simple as crawling is nice to create tension as well.

And so we need to be able to build the ability of the entire wall, the front side hip, the front side belly in an oblique fashion, all the way to that shoulder, which is the throwing shoulder across the body. All of it takes the movement. And I was talking to, I was talking to someone recently, uh, I don't know if I can release their name or not, but let's, uh, I was talking to them, someone about fascia and I don't know all the current thoughts about fascia, but, um, I'll just, I'll re I'll let you hear one of my original ideas here is that, so the, the whole thing about fascia is that they, they, they, everyone's considering that this is, it's a possibility that it transfers load. And so I saw an example of a, of a fresh cadaver. And so the, it didn't, it didn't look like it really appeared that the, that the fascia really had a large ability to transfer load to me anyways. And so I started thinking about this just from a neurological perspective in life with the fascia. I, I, I think, I think that it has a receptor, a bunch of receptors and afferent receptors.

So it tells you where your body's at in space. And so I started thinking about like with the hand, right? And so we have these three calluses. We don't have calluses on the thumb and the index finger, really, unless you're, unless you're hitting baseballs and stuff. Then that, in that case, you have one of the inside part of your, of your thumb and you have these pivot point ones. But when you're carrying stuff or holding onto stuff or hanging from things, you get the last three. And so I think the thumb is an opposition one and the finger is a dexterity. And so you have to, it's a little bit more free. And so these three fingers, I think, link in the body's inherent system and inherent pattern that says, holy shit, you're holding on something heavy. Let's go.

Let's link everything up here. And so the shoulder blade works. This, the shoulder girdle works. The, the rotator cuff turns on the elbow locks. And all of a sudden now we're carrying a lot of weight in an in an optimal way, in a safe way. And so I think that that linkage system, I feel like there's a possibility that the fascia really just tells us when to link things together. And so when we're throwing here, we have tension in all these different groupings that help sling the ball forward and protect the body from really opening itself up and deforming stuff on the other side, which then would pinch up like, like the facets say, and, and, and the shoulder would, would chicken wing itself off. And so I think the fascia is a receptor mechanism for tensioning the entire system in that, in that plane. My thought though, this might be a little bit much for patient to hear, but, uh, you know, I thought it'd be an interesting thing. So anyways, um, just take that from the light it was intended. I don't know for sure. It's just a theory I have. And I think that if you're a patient listening to this, just notice that if you didn't understand all that part, that's okay. Just realize that it's more complicated than, than just the shoulder.

The entire body needs to be conditioned here to be able to restore what the shoulder is attempting to do. And it really, it's just about offloading the areas. And so if we're talking about labrums again, sure, the, the labrum of the cartilage doesn't heal extremely well. They say because it's, it's a vascular doesn't have a lot of blood supply and that, that, that, that, yeah, that does happen. But again, consider that the labrum doesn't always hurt if it's frayed. Okay. Grade one labrum tears typically don't always hurt. Grade twos were rent venturing into that range. And I, and then, then we go further up and they get out of the realm of someone like me, or probably out of the realm of, of a PT and chiropractor and ATC. We got to refer up the ladder a little bit, but just know that if, if you're responding well to rehab, there's probably not a big need to go in and surgically change things. And it's all going to be based upon what you say and what you do and make sure that you're doing the homework. And so I've had patients before where they, they come back in and they say, look, I, I, I'm not any better. I say, did you, did you do your homework? And they say, no, well, a little bit. And so I, I just, I just tell them straight away, I say, look, I want you to know that, that I'm, I'm working off the things that you say and what you've done.

And because, so there's, I'm working off of, I'm trying, I'm trying to work on theories here. I'm proving and disproving theories in your rehab. Then it doesn't always happen in one day. Sometimes we lock out and we do it in one, you know, sometimes it worked extremely well, but other ones it's, it's testing the theory. And if it doesn't work, then it doesn't work. And then I'm not going to stick you in that box. We just need to figure out what's going to work for you. But if you don't test the theory, then we don't know if it worked or not. And so we're still on square one. So if you're doing the homework and you're getting better, there's probably not a big need again, to go have your MRI done. Unless you're looking for sinister pathology or things that will change the, change the game plan. A fracture would change the game plan. So there's a lot of things that could change the game plan. And by the way, just so everyone does know that you really can't see pinched nerves too much on the shoulder MRI. And so if you, if you come in and say, look, I had x-rays done of the neck and I had a shoulder MRI and they didn't see any pinched nerve. It's like, well, no, no kidding. You know, and nerves are similar to other things where sometimes we need to see the dynamic movement of it. And sometimes things will, will pressurize and pinch within a small range of motion when the head is tilted or turned. And so those are important considerations. Just know the imaging is not gold. All right. It doesn't show everything. It just shows us a story. And I know I focused on imaging quite a bit in this episode here because I think the imaging is a blockade of success for a lot of people. And if you're married to what you're, what it says on your image and you're married to the idea that that is what is generating your symptom, it's probably not going to change.

You know, like, um, like you, if you see, if you read my book, my, my low back disc did not change. It's still the same and it feels fine. And I think you're going to see a lot of friends and family who have gone through this before you, who have gotten better, who feel better, who are able to do what they're, they're going to be doing or what they want to do. They want to play golf or baseball or, or, um, whatever the heck it is, crawling around the ground that they can do it again. And I bet if you ask them, say, Hey, did your, did your MRI ever get better? Did all the stuff on your MRI ever get better? They're probably going to say, I have no idea. And some people, they don't even care. But I bet if you wanted to figure out the answer to this, you just pay for another image for them. I think they're, I think they're under 500 bucks here. You pay for the exact same image and just compare just, just for fun. If you are not convinced, I bet you're going to find the exact same thing. It might look a little less angry in there, but I think you're going to see that there's the exact same thing going on, but the person doesn't hurt. Okay. Pain's a little bit more complex than just structures. Um, the structural damage, there's more going on than that.

And the analogy I typically give people is like, look, if, if there was something severely torn in there that is damaging to, uh, or it's painful and it's the pain generator for what's going on, no matter what position we put you in, no matter what movement we put you in on your back, seated, standing, doesn't matter. It's still going to hurt. And funny story. I don't know if you guys have heard this one for me yet is actually, so my mom, my mom was an interesting story is, uh, she came in one time to pick my dog. It was, uh, God, it was, it's probably, this is probably about three years ago now. And so I was learning musculoskeletal ultrasound. I was in with a sonographer, which I've had, um, which I've had come on air before, uh, Mike Jablon. And so we're learning about the shoulder. And so I know she had a rotator cuff tear in the past, the supraspinatus.

And I said, look, can we, can we check that out? And so we looked at it. I'm not kidding you. The, the supraspinatus was literally blown off the bone, just gone, retracted, full thickness, retracted tear. And so we looked at each other. We're like, holy shit. We're like, do you have any pain at all? She says, Nope. Can you raise your arm? She went straight overhead. No problem. Not until we actually isolated down the supraspinatus a little bit more, uh, a little bit more well, did we find weakness so we can push her down with the pinky finger. She didn't have any pain. And so now that kind of prods a little bit of just because something's torn off and really, really, really, really messed up. Does that cause any pain? And the answer is, I don't think so.

You know, I think there's more to it than that. And I think though, that if you get with a healthcare provider who understands all this stuff, you're going to be in a good place. All right. Many, many more people than you think have gone through this before you. And I think you're going to be just fine. Or I guess I can't say for sure, but a lot of people are. Um, I, I, I, I'm trying to remember the last, uh, shoulder case I had to refer off for surgery. And, uh, there, there was one over the last couple of years. Um, I don't recall another one. I have people, I have people, uh, come in with, with post-op shoulders, but there was only one that I thought, yeah, I really can't help this person out anymore. Um, but I, they're, they're rarer than, than you think. So just know that if you're overall high functioning, it only hurts every once in a while. Just, just get with someone. It might be quicker than you think. So I think that's all I have for this podcast today.

But, um, if you enjoyed this, feel free to share it with another friend who has a shoulder condition. If you're a clinician who is, um, enjoying the message that I'm trying to put out, please share it with your patients. Um, although not all of these podcasts are extremely patient friendly, some of it business related and so on. Uh, if you have a question about which ones are which, just, just email me. Uh, I can put a list together of all the ones that are, they're helpful for a different pathology and conditions that you probably talk about a lot in the office. And I know one that I'm going to hit really quickly here is actually loading again, because I think I've had the conversation about loading, um, with people many times. And when we start getting into like, let's say we had a shoulder case like this, we start, um, adding a row in like a horizontal row and their shoulder feels better. Like, huh? Well, what else should I be doing at the gym?

You know? And that gets into the whole, uh, idea that everyone, a lot of people go down the route of the old bodybuilding honor model and they say, well, are bicep curls okay? And I say, well, I never really do them personally. And they say, well, you got big biceps. So you, what do you do? And I say, I do pull ups and like, oh, I can't do a pull up. And so this conversation keeps going and going and going and going. And I, and I don't mind having it cause it's helpful to the person, but I know too that they're not going to remember all the parts of it. So I'd rather just, um, do it. Um, I'd rather do it on podcast. So if you guys are looking for more useful things like that for your patients, just, just log on, subscribe like this, review it, please. By the way, if you haven't reviewed the podcast, I would love it for you to. Um, and lastly, um, check out that book. If you're, if you're working with patients with back pain and they talk about their friends and family with back pain, it's a useful book. It's really useful. It's, it's, it's under 20 bucks and shit. The candles, Kindle's like $7, $8. The audible is like a four and a half hour. Listen, it's quick. Um, and it's the full intention is to get people just into care. All right. Um, it's not to drive people necessarily to online programs and stuff that I have, although there's something on there.

That's mainly for the people who are not around somebody. And I, I'm very clear about it in the book. I say, look, um, this book is intended to, to get you motivated to do something with someone that you can trust. And I want them to find someone like you clinicians out there who know what to do with this kind of thing. So it's a win, win for everybody. And, uh, I mean, back pain is, it's an epidemic here. So let's, let's handle it. So leave people better than how you found them. And date, if you're dating, date an Eagle Scout. Talk to you guys later.