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

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Presentation on theme: "Staying Afloat, Keeping the Wheels Down and Feet Forward Prevention and Management of Repetitive Stress Injuries in the Triathlete Dr. John L. Michie."— Presentation transcript:

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

2 Experience  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

3 Program Highlights I.Mechanisms of Injury II.Applied Kinesiology and the Kinetic Chain III.Connective Tissue Support IV.Managing Inflammation V.Self Corrective Measures VI.When to Seek Treatment and What Modalities are Best?

4 Common Injuries of the Triathlete  Runner’s Knee/Patella Femoral Syndrome/Chondromalacia  Achilles Tendonitis  Swimmer’s Shoulder  IlioTibial Band Friction Syndrome  Sciatica (Discogenic and Piriformis)  Sacroiliac Syndrome  Plantar Fasciitis

5 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

6 Ken Hutchins “Exercise is not an Adjunctive Therapy, Exercise is the Therapy.”

7 Mechanisms of Injury Repetitive Stress Trauma  Triathlon training consists of massive repetitive stress to multiple body regions!!  All endurance training consists of repetitive stress!!  In RST, Connective Tissue failure occurs due to excessive loading and/or poor biomechanics

8 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 Collagen

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

10 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

11 Inflammation! Cardinal Signs:  Heat  Swelling  Pain  Redness  Loss of Function

12 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!

13 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

14 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 pressure  Nerve injury may result due to persistent pressure  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

15 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…..

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

17 Treatment Protocols Acute Phase:  Goal: Control Pain and Inflammation  “PRICE”  Protect  Rest  Ice  Compression  Elevation

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

19 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

20 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!!

21 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

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

23 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, Protrypsin)  Omega 3 Fatty Acids/Fish Oil – 6-9g/day

24 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  Devil’s Claw Extract  30-90 day high dosing for pharmacological effects!

25 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)

26 Runner’s Knee Causes:  Pronation  Q-angle (Women > Men)  Quadriceps Imbalances/Weakness  Tight Hamstrings and ITB  Short Hip Flexors  Road Pitch Repetition  Overly Supportive Training Shoes  Wearing Training Shoes beyond ~400 miles

27 Runner’s 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.

28 Runner’s Knee Management:  PRICE  Acute Physiotherapy protocols (Iontophoresis)  Nutritional Anti-inflammatory protocol  Strengthen Quadriceps  Myofascial release and foam roller @ 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 imbalances  Bracing for Patella stabilization and compression  Proprioceptive input training with balance board and bosu ball

29 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

30 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

31 Achilles Tendonitis Management:  PRICE  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

32 Swimmer’s 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

33 Swimmer’s 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

34 Swimmer’s 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!)

35 Swimmer’s Shoulder Management/Treatment:  PRICE  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, pectorals  Topical Traumeel  Shoulder rehabilitation protocol for A.C. Jt. Decompression (see shoulder rehab protocol)

36 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 shoes  Weak Abductors (Glute Med.)

37 ITB Syndrome

38  Symptoms:  Pain @ lateral aspect of knee  Pain below knee (lateral aspect – attachment)  Pain @ lateral lower thigh  Pain @ lateral hip  Pain increases with descending stairs and transitioning up from sitting  Pain increases with heel strike

39 ITB Syndrome  Management/Treatment:  PRICES  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 Iontophoresis)  Chopat type stabilizing brace  Myofascial release @ Gluteal group, Quads, Lat. Hams, Gastrocnemius  Restore strength to VMO to facilitate medial glide of patella  Foam Roller!  ITB Stretches

40 Sciatica  Discogenic: Bulging or herniated disc causing compression/irritation of sciatic nerve.  Piriformis: Deep Gluteal muscle causing compression/irritation of sciatic nerve

41 Sciatica 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

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

43 Sciatica Causes:  Spinal Stenosis  DDD  DJD  Spondylolisthesis  Disc Herniation  Trauma to back and/or hip/gluteal region  Training with mechanical imbalances in kinetic chain

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

45 Sciatica  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

46 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

47 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

48 Sacroiliac Syndrome Management:PRICES  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 @ Gluteal group, lower back, hip flexors, hams and quadriceps  Physiotherapy modalities (EMS, US, Iontophoresis)  Topicals (Traumeel, DMSO, Biofreeze)  Training modification

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

50 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!

51 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  PRICE  Orthotics cast  Kinesiotape  Myofascial release @ 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

52 Medial Tibial Stress Syndrome  “Shin Splints”  Periosteal inflammation due to overuse and pulling of the muscle from its muscle/tendon origin  Symptoms:  Pain @ 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 @ lower leg  Pain with ankle/foot/toe plantar flexion

53 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

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

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

56 Meniscal Tears  Causes:  Squatting  Twisting Knee  Degenerative changes  Age  Biomechanical Imbalances  Repetitive Stress

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

58 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!!

59 Adrenal Fatigue Symptoms:  Fatigue!  Blood Sugar Fluctuations  >BP and >HR  Depressed Immunity  Increased fat storage  Depression (decreases Serotonin)  Elevated cortisol levels promote Inflammation  Altered sleep quality despite exhaustion  Tight muscles and aching joints

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

61 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

62 Adrenal Fatigue Management: Nutrition: 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 - > B5, B6, C  Support as needed based on labs, upstream involvement!

63 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

64 DDD/DJD 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)

65 DDD/DJD Symptoms:  Joint Pain – Sharp and/or Ache  Referred Pain – Primary and Secondary Hyper- Algesia  Mechano-receptor pain  Loss and Painful ROM  Swelling and localized inflammation  Crepitous  Excessive Stiffness  Frequently pain lessens with activity

66 DDD/DJD  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, ICE/MH)  Aqua therapy – Exercise and Epsom Salts baths  Anti-inflammatory nutritional protocol!!!  Joint integrity nutritional protocol!!!  Avoidance of pro-inflammatory mediators (Grains, Dairy)  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 compression

67 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.

68 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

69 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

70 Lower Extremity Stress Fracture Management:  Diff. Diag.: X-Ray inadequate! MRI, Bone Scan!!  PRICES  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

71 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.

72 Rotator Cuff Tendonopathy Symptoms/Mechanism:  Elevated pain sensitivity due to increased development of nerve and blood vessels (neovascularization)  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 affected side  Painful arc movement – up or down  Short Pectorals and anterior shoulders!!  Intrinsic shoulder/RC muscle weakness  Scapula rhythm altered!  Inadequate extension emphasis

73 Rotator Cuff Tendonopathy Management:  Diff. Diag.: MRI, Clinical Examination  PRICES  Physiotherapy (EMS, US/Phonophoresis, Iontophoresis)  Dry Needle Therapy  Myofascial Release Tx.  Manipulation/Mobilization @ 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 techniques!  Avoidance of overhead and push movements temporarily  Orthopedic Eval. (Cortisone and/or decompression in difficult cases)


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