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Persistent Shoulder Pain

Persistent Shoulder Pain: Avoid The Cycle



Have you had shoulder pain for a while?



You don’t remember any clear injury, but the shoulder pain just won’t go away!



At first your shoulder pain was sometimes and tolerable, now your shoulder pain is relentless and impacting your life!

Sound familiar?


Does this resonate with you? If so, read on!


The Never-Ending Pain Cycle


You’ve been stuck in this rut for a while now. The shoulder pain just won’t go away, so you go to see your doctor.


You walk out of there with advice to rest the shoulder from all activity and take a cocktail of medication.


You rest, avoid doing the things you enjoy, and the things you need to do. Frustration grows, but the pain settles. The journey has come to an end, back to normal life!


You begin some activities again that used to aggravate your shoulder, then there it is again, that familiar shoulder pain! Below is a diagram to show what is going on.



Back to the doctor. FRUSTRATED, ANGRY and FED UP. A scan gets organised.


The scan comes back, and there’s all these words: degeneration, arthritis, subacrominal bursitis, rotator cuff tendinitis, rotator cuff tear, and so on.


That’s it! That’s the reason! So, a corticosteroid injection is organised.


The needle is HUGE, the injection hurts. It’ll all be worth it though! Right? You’re told to rest for another 2-3 weeks. Your shoulder pain either:

  1.       Doesn’t change at all!
  2.       Reduces, but doesn’t go away
  3.       Returns a few weeks later
  4.       Returns a few months later


When will this end? The scan said what was wrong, didn’t it?



What Does My Shoulder MRI Mean?


Medical imaging can be a very useful tool in diagnosing certain conditions. However, sometimes they can see a little too much!


As we age our body changes. We get greys, we get wrinkles, we get changes to tissues inside the body. These changes are completely normal, and exist in lots of PAIN FREE people.


Wait! What?


Research is piling up every day of PATHOLOGY seen on imaging in PAIN FREE people, all over the body!


One particular study of the shoulder reported 70% of PAIN FREE people had mild shoulder arthritis. They also reported that 90% had mild-moderate subacromial bursitis! Read that again, 90% of PAIN FREE people with NO HISTORY of Shoulder Pain had a pathology.



What About Rotator Cuff Tears? Surely A Tear Causes Pain?


In this same study 60% had either a partial or full thickness supraspinatus tear, and that’s only one of the rotator cuff muscles!


Starting to see why the corticosteroid injection may not have worked? The pathology on imaging may not be the reason you experience pain!


So what’s the answer?



Shoulder Anatomy & Human Physiology 101


The shoulder joint is made up of two bones, the scapula (shoulder blade) and humerus (arm bone).


The shoulder joint is designed for mobility! This is hugely beneficial; it allows us to accomplish many tasks in our daily lives, sports, or jobs.



But, Having Mobility Requires Stability!


Stability of the shoulder joint is provided by two muscle groups; the rotator cuff, and the scapular muscles.


The rotator cuff is a group of muscles that provide dynamic stability of the shoulder joint. When their strength and activation is less than what your body needs for the tasks in your life, your shoulder can become prone to irritability.


The scapula position and how it moves can also influence how your shoulder joint moves and functions. Stability of the scapula is also integral to a happy and healthy shoulder joint.


Starting to make sense why rest hasn’t worked?


When our muscles and tissues have prolonged rest, their capacity reduces! If you reduce your capacity, your tolerance to load (daily activities, work, sport) also decreases.



How Do We Break The ‘Never-Ending Pain Cycle’ At Paramount Physiotherapy?


  • Restoration of scapular control
  • Regaining full range of motion for the shoulder
  • Restoration of rotator cuff strength
  • Restoration of shoulder proprioception
  • Restoration of sport specific capacity – strength & power
  • Return to work or sport


Mark Walters (APAM) 


Simple Guide to Low Back Pain



Low back pain or lumbar pain, is very common, with it affecting two-thirds of adults in their lifetime. So you are not alone!


I understand that there is a lot of info coming at you about what you should and should not do for low back pain. This article will provide information around the injury and some strategies to implement in the early stages of your journey.


What is Low Back Pain?

Lower back pain can be categorised into the following categories:

  1. Specific Spinal Pathologies (<1%)
  2. Radicular Syndromes (5-10%)
  3. Non-Specific Lower Back Pain (90-95%)

As you can see, the majority of lower back pain cases are non-specific in origin. Meaning there is no specific structure that we as health professionals can state is injured and is the cause of the back pain.


Let’s go further into Non-Specific Lower Back Pain

Non-Specific Lower Back Pain is an experience of pain typically due to the following overarching factors:

  • Traumatic back injury
  • Erratic physical loading
  • Insidious onset


Within these categories, there is a multitude of reasons that are associated with why someone has spinal pain. These include [1]:

  • Sustained or repetitive positions and postures
  • Physical deconditioning
  • Life stresses
  • Emotional factors: stress, anxiety, low mood, anger
  • Poor coping strategies
  • Poor beliefs around pain and injury
  • Poor sleep
  • Poor nutrition
  • Low or highly erratic activity levels


What are the symptoms for low back pain?

You may experience sensations from a dull ache to sharp persistent feeling locally or into the buttock.

It may stay local to the lower back region, but it is not uncommon to have referral pain into the buttock and legs.

You may struggle doing normal daily activities such as bending down, straighten your back, getting up from a chair.

Your mornings will feel stiff and sore and will take about 30 minutes to get up and moving.

DON’T FRET…. All of these are normal symptoms!


What are the recovery expectations?

The above symptoms are all part of the body’s natural healing processes. So realistically, by having these sensations means you are on your way of getting back to normal life!

It won’t be smooth sailing! The duration of healing for most soft tissue injuries will take up to 6 weeks.

Pain itself will vary from person to person, but the worst of it is usually within the first 2 weeks and it will decrease in intensity over the 6 week period.


What should you do initially?

The very first thing to do when experiencing acute low back pain is to apply hot or cold therapy (this is a contentious issue and an article in itself), which is up to you but both can be tried to know which one is most effective.

Cold Therapy – Shortly after encountering the pain, apply an ice pack on the location and this can help by reducing the inflammation and interfering signals of danger to the brain.

Heat Therapy – Right after the occurrence of the ache, place a heat pack to the back muscles affected and this can provide comfort by giving good blood flow to the injured area and by increasing mobility to areas with stiffness. Another way of doing heat therapy is by engaging to moist heat like hot bath or shower.


What are some simple exercises to do for acute low back pain?

When experiencing an acute low back pain one must bear in mind to never stop moving. Daily routine and activities should be continued for as long as it is well tolerated.


The best advice is to remain active using these simple exercises:



If still able, a 10 to 20 minute walk once or twice a day will do a world of good. Walking will not only do all the good stuff that a heat pack can do, but also tell your brain that movement is safe and okay! This is key to the whole process!


Gentle Movements 

If you feel better standing up, then do some simple movements based on that position such as a standing lumbar extension.


…or a lying lumbar extension


If sitting is a preferable position, then we can choose a movement that promotes flexion such as a lying knee-to-chest exercise.


Or you can also complete gentle knee rocks moving from side to side whilst lying on your back


 Who should you see?

Pain usually subsides for lower back pain with or without treatment.

For specific guidance, an individual assessment from a physiotherapist with a special interest in back pain, such as a musculoskeletal physiotherapist, is the best option.

Your physiotherapist should be able to categorise your back pain, rule out any serious spinal pathologies, provide a management plan that not only looks at self-management but strategies that will reduce the risk of injury in the future.



David Bruzzese (MPA, AEP)

APA Musculoskeletal Physiotherapist & Accredited Exercise Physiologist



[1] O’Sullivan, et al (2018) Cognitive functional therapy: An integrated behavioural approach for the targeted management of disabling low back pain

3 Truths Behind Hamstring Strains




1. Current evidence related to the mechanism behind a hamstring strain, the importance of particular exercises that can decrease the risk of hamstring strains


2. Exercise programming for the individual returning from hamstring injury.


3. How a hamstring rehab program can be a great hamstring strain prevention program!


What Is A Hamstring Strain?



Hamstring strains, normally classified as proximal or distal strains, mostly involve eccentric muscle action and generally occur in either a sprinting-type activity (e.g. leg deceleration in terminal swing) or stretching type activity (i.e. picking up a ball) (Tsaklis et al 2015). 


So very common in sports that involve high levels of sprinting and agility such as AFL, soccer and sprinters. 


Though a majority of function may be restored when an individual returns to play, eccentric hamstring strength has shown to be inadequate and a contributing factor to the high hamstring strain recurrence rates (Askling, Saartok & Thorstensson 2006).


Hamstring muscle group


Truth 1: Exercises Can Decrease Recurrent Strains!



Fascicle length


A muscle fascicle is a bundle of skeletal muscle which increases in length after resistance training, usually eccentric training. There is a significant correlation between short (measured by fascicle length) and weak biceps femoris with hamstring injuries.



Muscle fascicle


Prior hamstring injury and biceps femoris fascicle length is shown to have a strong relationship with each other (Alonso-Fernandez, Docampo-Blanco & Martinez-Fernandez 2017). With no previous hamstring injury, a relationship exists between shorter fascicle length and increased probability of hamstring injury (9cm associated with 38% likelihood, respectively).


With previous hamstring injury, the probability is significantly greater with a shortened fascicle length (9cm associated with 65% likelihood, respectively) (Opar 2016). Though the non-modifiable risk factor of previous hamstring injury is set, we are able to use exercise to modulate the modifiable risk factor of fascicle length.


Below is a graph demonstrating the relationship between bicep femoris fascicle length and Nordic strength. With a weak/short biceps femoris had a 40% probability of hamstring strain compared to 3% probability with a strong/long biceps femoris.


Quadrant of doom (Courtesy of In:Motion Technologies)


Truth 2: Eccentric Exercises Are Awesome!



Contraction type


Muscle contraction types have an effect on fascicle length adaptation. After a 6-week concentric or eccentric only hamstring strengthening program, both eccentric and concentric exercise adaptations occur within 2-weeks of an exercise program. With concentric training, there is a change in fascicle length by -13.3% at 6 weeks.


The shortened fascicle adaptation is maintained after the strength training stimulus is removed (-12.2% at 10-weeks). Moreover, eccentric training has a similar but opposite effect on fascicle length, fascicles lengthen (14.1% at 6-weeks and 0.8% at 10-weeks) yet all adaptations are removed once the eccentric training stimulus is removed.


This highlights the importance of continuing eccentric hamstring exercise application as a preventative measure of recurrent hamstring strains (Timmins et al 2016).


Contraction types


Truth 3: Hamstring Strength Is Not Enough





During detraining periods, as previously discussed, once the eccentric training stimulus is removed, fascicle length adaptations are lost. However, though there is a loss in fascicle length, only small losses in strength adaptations associated with eccentric training are observed (Timmins et al 2016).


This is an interesting finding, as it may demonstrate why so many athletes will return to sport with adequate strength, but may reinjure in the future. It may be related to either the lack of eccentric strength work completed during their rehab or the cessation of eccentric exercises once they return to play.


What can we do about it?



The goals of a well-rounded hamstring rehab program is to cover these areas:


1. Concentric/Eccentric Long Length

  • Hip extension based exercises that keep you locked at the knee and bending forward at the hip
  • This is really important for footy players as the requirements of the game involve bending down and picking the ball from the ground


2. Concentric/Eccentric Moderate Length

  • These are your bridging based exercises
  • We can really work at developing strength and power with these exercises


3. Eccentric Only

  • The Nordic curl (as discussed above) are the perfect example of and eccentric only exercises
  • These are quite difficult, so there are many variations that allow someone to slowly progress to a full Nordic exercise. As stated, this process can take weeks to months, depending on the individual’s hamstring capacity


4. Gluteals

  • We need the gluteals to work with the hamstrings
  • There are many exercises that can be done for glute strength. The key is to make it relevant to the sport and have a focus on control


5. Whole/Neuromuscular

  • This involves a full body movement that incorporates a mixture of trunk rotations, upper body strength and single leg exercises


6. Running Mechanics

  • A gradual running/sprinting program is vital for hamstring rehab and should be progressed over 3-6 weeks (depending on severity of this strain)


Now, if you have not covered all these areas in your previous hamstring rehab programming…it is likely that you have re-injured your hamstring at some point OR at increased risk of straining your hamstring.


Final Thoughts


What we see in the clinic quite often are athletes returning to their given sport too early after they have strained their hamstring. They usually think:


“My pain is gone, so it must be healed”


“I can lift heavy deadlifts, so my hamstring should be strong enough”


“It’s just a little sore, it should be right”


We need to ensure that we tick all the boxes before a safe return to sport and decrease the risk of re-injuring your hamstring.


If you would like me to call you to discuss your previous or current hamstring program, whether you are on the right track for preventing a future hamstring & how we may be able to offer you a solution, then please fill in the contact form below and leave your best contact number. 


If you’re sick of constantly “doing your hammy” and just want to get back to it without any worry… follow the book online link in the top right corner & we hope to help you soon!




David Bruzzese

APA Musculoskeletal Physiotherapist & Accredited Exercise Physiologist




Alonso-Fernandez, D, Docampo-Blanco, P & Martinez-Fernandez, J 2017, ‘Changes in muscle architecture of biceps femoris induced by eccentric strength training with Nordic hamstring exercise’, Scandinavian Journal of Medicine & Science in Sports, pp. 1-7.

Askling, C, Saartok, T & Thorstensson, A 2006, ‘Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level’, British Journal of Sports Medicine, vol. 40, pp. 40-44.

Timmins, RG, Ruddy, JD, Presland, J, Maniar, N, Shield, AJ, Williams, MD & Opar, DA 2016, ‘Architectural changes of the biceps femoris long head after concentric or eccentric training. Medicine & Science in Sports & Exercise, vol. 48, no. 3, pp. 499-508.

Tsaklis, P, Malliaropoulos, N, Mendiguchia, J, Korakakis, V, Tsapralis, K, Pyne, D & Malliaras, P 2015, ‘Muscle and intensity based hamstring exercise classification in elite female track and field athletes: implications for exercise selection during rehabilitation’, Journal of Sports Medicine, vol. 6, pp. 209-217.


Welcome to Paramount Physiotherapy

Hello everyone,

Welcome to Paramount Physiotherapy. Writing this first blog on a Friday evening, we are filled with excitement to meet you all. We are beyond thrilled to be able to provide the Inner West of Melbourne with a multi-disciplinary clinic. Services include physiotherapy, Clinical Pilates, exercise physiology, massage and running assessments.

At Paramount Physiotherapy, we are committed to educating and empowering people in their health and fitness. Alongside our educational videos found on Facebook and YouTube, this blog will be full of tips, explanations and links to widen your understanding of injury, pain and rehabilitation.

So, keep your eyes and ears wide open for upcoming material on all things rehabilitation, health and fitness. If there is a particular topic or question that you may have for us feel free to email us. We’re here to spread information and further everyone’s understanding of the human body and movement.

Enjoy the blog and follow us on Facebook and Instagram for more content.

Get Strong, Stay Stronger – The Paramount Physiotherapy team