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Hello El Paso! This is Dr. David specialist physical therapist from El Paso Manual Physical Therapy and I'm bringing you today the Stay Healthy El Paso Podcast. We are going to be talking about why a rotator cuff tear happens, and the three-phase process to naturally fix it.

Here in the clinic at El Paso Manual Physical Therapy we follow this three-phase process. There is a lot of detail to it, I'm just going to give you an overview about it. It is possible to adapt it for yourself at home. We teach our clients here, how to do it at home. And we will get into all the details about it.

But first, I want to answer the classic question that we get from every patient that comes into the clinic as we see them regularly. With a rotator cuff tear, they always ask, “How did this happen? Why? I was fine last month and now this is happening, and my shoulder hurt me a little bit, but now it hurts a lot and I can't do a lot. And we are going to go into that.

Let's get started with just talking about what the rotator cuff is and why it's important for your shoulder.

There are four rotator cuff muscles and tendons, and just to talk about muscles and tendons real quick, muscles I think most people get, is the part of your body that when you tighten it up, it gets harder and it moves your joints like in your in your bicep. Everybody thinks about that, the flexing muscle in your arm. The part that everybody wants to have bigger, the big biceps. That's the muscle.

What most people don't understand though, is the tendon is at the end of muscles and attaches the muscle to the bone so that when the muscle contracts and squeezes, it yanks the tendon which makes the bone and that's what causes movement out of joint. So up in the rotator cuff, you have four rotator cuff muscles, and they all have associated tendons that connect to the shoulder to the, what's called the humerus, the upper arm bone, and it pulls the ball into the socket. It is heavily important for the stability and fine-tuned movement of the ball and socket joint in the shoulder.

The four muscles really quick, are the supraspinatus infraspinatus, the subscapularis and the terry's minor muscle. All four of those come together to form the rotator cuff. Now when you get a rotator cuff tear, it's most commonly in the supraspinatus tendon, which is the one that's closest to the top of the joint. And there are different types of tears. If you have a tear out there, you'll be familiar with these terms. And the way they find these is usually with an MRI.

By the way, if you haven't had an MRI then chances are you haven't been told these terms. But if you have had an MRI then this is going to be familiar to you. You might have a partial thickness tear, also called an incomplete tear and a full thickness tear are, also called a complete tear.

Partial thickness tear just means that the way the tendon tore, it's almost always the tendon, that tears, by the way, when it comes to the rotator cuff. It's only partially torn or detached from the bone. It's not fully torn or detached. So it's still hanging on. It's still being used to do its normal function in the shoulder.

Now, a complete tear means it's just about nearly detached from the bone. What I see is that most people can still use the muscle when they have a complete tear. That indicates that it's still attached somehow. But it's probably hanging on by a thread is really what's going on.

You have to understand with MRIs, they are not the gold standard to an MRI. In other words, what's better than an MRI is going in with a surgical camera and observing or looking at the tendon. That's the true way to diagnose a tear. But of course, surgeons aren't going to say, well, let's just do surgery to stick a camera in there. Just to diagnose it, they are not going to want to do that. They are only going to do that if they are going to actually do something about it.

Then MRI is the next best thing because it is an invasive, it takes a picture of the inside of the body, but it's not as good. So that means that there is a possibility for the MRI to be wrong about how bad the rotator cuff is torn. In some cases, it's completely wrong where there isn't a tear at all. But the MRI is showing that there is a tear. That's called a false positive.

In the medical world, you can also have a false negative. But anyways, what a false positive is, you go get an MRI and the doctor says based off the MRI, you have a rotator cuff tear, whether it's full thickness or partial thickness. And the way that you find out that it's false is when you end up having a surgery for it and surgeon says there was nothing wrong, and they don’t know why your shoulder is hurting because your rotator cuffs is just fine. They usually just close you back up and maybe they cleaned up a couple things that they could find, but you really didn’t have a tear. Then you had a false positive MRI.

I just want to give you a heads-up MRIs are not always 100%. Right? But what they are good at is blatant problems. They do find blatant, huge issues, but smaller issues that aren't as, as significant they might have a false positive.

Some other differentiations to make within rotator cuff tear types is acute versus degenerative.

An acute tear means that it just happened because of some event, like you were in a car accident or you fell, or you had a bike accident, something like that. Some trauma that happened that caused you to tear the rotator cuff, versus degenerative. The way that typically comes on is, there was no trauma, there was no events that happened, a fall or accident. It just started hurting one day.

It might have been something trivial that set it off like, I went to go pick up that gallon of milk or that full coffee pot, or I was picking up the laundry while doing chores at home, or I worked a lot at home, I did a bunch of gardening or this project outside. And by the end of it, my shoulder was just killing me. And the next day it was hurting even worse, and that's when I decided to go to the doctor and then they said that I have a tear.

So very likely wasn't just that coffee pot that you picked up, or the six hours that you spent doing that project at home. It was an accumulation of problems that were minor. It just happened that you passed the threshold of pain and activity to really set it off. And further tear the tendon and make it worse.

But most often these people have had some shoulder issues here and there. They may not even be painful. By the way, some rotator cuff tears are completely painless, but they just can't pick up their arm all the way, or they lose function. The way that most people lose function by the way, when I say that, it means they can't raise their arm all the way up overhead like the candle or their arm.

Reaching out ahead or at an angle, or you just can't even reach all the way out there, you don't have the actual strength or ability to get there. Reaching behind the back is very commonly limited as well like if you are trying to scratch an itch in your back, or fish the belt or the belt loops behind your behind your back. Or for ladies reaching for a bra strap behind your back is painful or just not possible with these rotator cuff tears.

Those are the different types, there are full thickness, partial thickness, and then there are acute and there are degenerative. Now as you probably already thinking, a full thickness tear is worse and an acute tear is going to be worse, and those are the ones that are more likely to have surgery. Obviously, if you have a partial thickness tear, then you have a better shot at getting better without surgery. And if it's degenerative, then usually you can fix things and prevent it from getting worse, because it wasn't some trauma that was out of your control, it wasn’t an accident.

There are cases though, and we've seen them here in the clinic where people come in with MRIs, it's a full thickness tear, and they look pretty bad. And it turns out to be degenerative. It's been going on for a while, and they get better. They get completely better, completely escaped their surgery. We've had it consistently, I'd say a few times a year, three, four, maybe five times a year, we get people that are actually scheduled for surgery. When we talk to them on the phone, I hear this from the staff that answers the phone. They'll say, Hey, you know, we booked so and so for a visit with you with you next week. And be careful with this person, because they are actually booked for surgery at the end of the month, and they are just seeing you for a second opinion.

Once we see them in person, and we talk to them, I do all the testing and we find out that they are actually a great candidate to do therapy before surgery. And I always tell them, Look, if it's that urgent for you, please go get the surgery. I'm not going to tell you not to. Obviously, it's your decision. It's your shoulder. But if you can wait maybe a month and see how this goes as far as physical therapy. Then if it's getting better gradually you have an excellent shot at rehabilitating this problem naturally, without exposing yourself to the side effects and the risks of surgery.

Plus, the big factor for that person is that they are going to learn what to do to keep their shoulder healthy for the long term. Which surgery just doesn't teach you, you just show up for a surgery date and they take care of the rest, you lie on the table and they do everything for you. And they do a great job. By the way, if you have to have a rotator cuff surgery, all the ones that I've seen, they are done so well they do a fantastic job.

There are some surgery cases that don't turn out too well as with every surgery, but I see that less with rotator cuff repairs and with certain other surgeries. It's not the worst surgery in the world to have but it's still surgery. You still might get an infection, there are still risk for other problems to happen.

Let's talk about the reasons for these degenerative tears. Obviously for an acute situation, where you fell, had a car accident, or something happened. The reason for it, there was an obvious problem. But when there is no accident, people are left wondering to themselves, what the heck, what did I do? There are four main components to this. Let me go into each one.

Posture is one, if you tend to be in a slouched posture because you work at a desk, or that's just been your posture, chances are it's not a hard and fast rule, but chances are within your shoulder joint ,within the ball and socket joint, your joint isn't properly aligned when you are in that posture. You tend to shut down some of the muscles in the area as well, which causes the ball and socket joint to not be most congruent, or the ball isn't in the socket as best as possible.

It's not out completely to where your shoulders and work but it's not seated in as best as it can be. And if you move like that if you live like that, if that's how your shoulders forced to work, then it begins to wear down on the rotator cuff tendons around it. Gradually over time, you wear it down. And when you wear it down, you begin to form a tear.

Occasionally, some people will say, yeah, my shoulder is kind of sore. When I pick it up, I just feel a little bit of pain, but I can do everything I need to, and it goes away after a while. I've lived like that for years. And then one day I was just miserable. I can’t sleep on that shoulder. I had trouble getting my shirt on and off or washing my hair in the shower. Simple things become very, very uncomfortable to do. So, posture is a big problem.

Weakness is the next one. If you just have a weak upper body, you are going to be predisposed to getting some sort of rotator cuff tear problem.

The shoulder itself the ball and socket joint. It's a phenomenal joint. The only other ball and socket joints in the body is the hip. And the difference between the hip and the shoulder is the bone structure of the hip. The socket is very deep relative to the shoulder. If you look at the bone structure of the socket in the shoulder, it's tiny. The socket itself is very tiny and surrounding the socket is a bunch of cartilage and other tissues, and the rotator cuff is a big stabilizing factor.

What you don't have to worry about in the hip is that it's more stable naturally because of the bone structure. But up in the shoulder, you have to rely on stability from these muscles. If you just are not strong overall in your upper body, you are very likely going to have stability problems in the shoulder, which leads to tears in the rotator cuff.

That's one of the first things that breaks down in the shoulder. So, if you are averse, if you don't like to go to the gym, and workout. I see this especially in females, because females just are more usually concerned about having strong legs and strong arms versus men are the opposite. They want to have strong arms or strong legs. Females tend to avoid working out their upper body which years down the road, can affect the rotator cuffs. We see a lot of these rotator cuff issues.

Now in men, when we see rotator cuff tears, it tends to happen in the jock type of person. The classic is somebody, It was a guy he's in his 50s now 60s even and very active. He has always played sports in high school, lifted weights, lovee doing bench press, because that's the guy lift the bench press. That's all the guys are going to be good at bench press. And usually they have developed some sort of big muscle imbalance within the shoulder that's causing that ball to not sit on the socket right.

It may not hurt at the very beginning, the first few years that is happening, but over time it can begin to cause a problem. And you can begin to get rotator cuff tears. Once you hit a certain threshold, that can be really painful. The degenerative type tend to happen when people hit their late 40s 50s. Usually, if they have had some shoulder problems leading up into their 40s and 50s, they definitely have them by their 60s.

So, if you are in your 30s or 40s, right now, you are already having some shoulder problems, you need to fix this issue before it's too late because you are going to end up getting a rotator cuff tear. You may already have a baby one going on, but it is possible to heal that. We will talk about that more here in a second.

Let's talk about genetics next. That's the third factor for a rotator cuff tear. Your shoulders index inside your shoulder, right above the ball and socket joint, there is a piece of bone from your shoulder blade that overhangs on top of the ball within the ball and socket joint. It's called the acromion. In the space between the acromion and the ball and socket joint, they call that the subacromial space. There are some structures in there, of course, were the rotator cuff tendons runs through there, the supraspinatus. There is a Bursa that commonly gets blamed for problems.

Everybody that has shoulder problems has some form of bursitis, shoulder bursitis. And some people go down the rabbit hole of trying to fix their bursitis when it's really a rotator cuff problem, or some other related problem. And the bursa just gets irritated because of it, but it's not the bursa's fault. It's other things fault, but people will go get injections for the bursa.

Anyways, that subacromial space can be reduced which can cause compression on the bursa. The rotator cuff tear or the rotator cuff, which can lead to a tear. And so, that space needs to be managed properly. Strengthening the muscles around the shoulder will allow the space to be more normal. Posture will also allow the space to be more normal, but some people have a different shaped a chromium which can genetically reduce the space, so they just have less margin for error. Those people with a certain type of a chromium shape need to just be extra careful that they have good posture and strength and they can manage just fine.

The fourth factor related to this chromium, the bone shape within their shoulder, is that if they are getting some rubbing on the rotator cuff tendon from that acromion of the degenerative changes within the joint is that they might get bone spurs on the bottom part of the acromion. A bone spur is just an increase growth on the bone. There are all these theories and why they occur. I'll just give you my take on it.

One of the principles in the body, one of the things that’s always true, is that the body adapts to forces. So just like if you get calluses, for instance, people get calluses on their feet, on their hands, other parts of their body, depending on what activities they are doing. A callus is a response to some sort of increased repetitive force on the skin. In order for the skin to avoid tearing and breaking down, it gets thicker, and it gets thicker to protect itself from when you go back to do that activity it won't tear.

The other parts of the body do that too. Just like if you go lift weights, if you are picking up weights to strengthen your muscles, your muscles feel the force of the weight that you are having to lift, and so they adapted by getting thicker and stronger. So that you can pick up the weights again easier and maybe even pick up more weights.

Tendons do the same thing. We know that bones do the same thing if you have osteoporosis for instance, it's recommended that you go do resistance exercise or body weight bearing exercise, because it tends to make the bones thicker so that they can be better able to sustain forces and not break as you get more active. Those bone spurs develope to protect the bone from breaking or becoming irritated or injured somehow. It's a sign that something's not right. In the overall mechanics, the way that you move your posture, your strength as well.

There is some imbalance somewhere, somehow, that's causing this bone spur to develop. If you have bone spurs on the bottom of your acromion it's going to decrease that subacromial space. And it can directly put pressure on your rotator cuff tendons, and just cause a tear to come along faster than other people. So that's just a genetic thing that some people have.

That covers the four reasons for getting a tear.

Let's talk next about how to naturally fix it. I'm going to give an overview of our three-phase process for naturally fixing rotator cuff tears. It's quite complicated. Whenever we take a rotator cuff patient on, we have to first see if we can help them or not, or if they really are the best candidate for surgery and they should go there first.

We always educate them. We say, Hey, if you are going to go have surgery, that's cool. That's your decision, or it's very appropriate, I recommend it too. I think you should go. You are not going to do too well, if we try to skip out on surgery, it’s just that far gone, unfortunately. But I tell them, you still need to go through physical therapy after. It's almost always the case. Whenever you have a rotator cuff repair surgery, you get sent to physical therapy. And the point of that physical therapy is to just get your motion back. Because you are going to be all stiff and swollen from your surgery, you are going to have to be wearing a special sling. You have to wear that thing at night, it's miserable to sleep with it, you are going to be in pain for a long time, usually three or four months after surgery.

That's just normal for everybody going through rotator cuff surgery. But all the physical therapist is going to get you to do, is begin to raise your arm up, move it out to the side, and move as your shoulder allows. They have to follow protocol and get it back to normal. When I say normal and air quotes because most people that have finished rotator cuff repair physical therapy after the surgery, they are not normal. They'll tell you, when I pick up my non-surgical arm, my good arm, they'll say, look you can come up and look at my other arm and they are lacking, good 20-30 degrees. They are not normal yet.

But they have made a lot of progress. Obviously, they couldn't do anything near that after surgery. So it's more functional for them, they can get through life, but they may still not be able to sleep on that shoulder, they may still have trouble using the arm and may be weak. Doing housework around the house is still a challenge for them.

There is still a lot of rehab that needs to happen on their own. Or they may still go to therapy for a while. And really, it takes the better part of a year to recover fully from a rotator cuff repair surgery. Then I tell these people that are going to go get surgery, that they still have to fix the underlying problem. If you think about it, if you had a degenerative tear, there is something about the way that you are moving, the strength of posture. Maybe your genetics is a factor, but there is something that you can modify, so that you don't have to have a surgery again. Because we see that happen.

We see people to get a rotator cuff tear, they go get a surgery, and then a couple years later, they are back at the surgeon's office because their shoulder hurts again, and the surgeon is saying you are developing another tear in the same area, I'm going to  have to go do a double repair. And I always tell them, there is something that wasn't fixed. That wasn't the surgeon’s responsibility. They likely did a fantastic job. It wasn't the surgery coming undone. It’s that there are issues that are unresolved here that need to be strengthened or moved better.

If we get somebody who's a good non-surgical candidate, they should have physical therapy like we have here, the specialized type of physical therapy that we offer, then I start telling them great, I'm glad you decided to start physical therapy with us, you are going to learn how to manage this, so you don't have to have surgery. And if for some reason you have surgery, you are going to know how to manage this beyond that, so that you are not having to have a second surgery.

Let's get into the three-phase program that we take people through.

Phase One, The Healing Phase.

We sometimes skip this phase, but it just depends on where the individual is at. If we get somebody in here, let me use our last case for example. Or the last one that we had in here, she is in her mid-60s, very active, loves to garden, loves to do projects around the house. She is a retired teacher and loves spending time with her family, loves baking, loves cooking, she just loves life and loves taking care of her family and her home.

It just slowed her down tremendously. Once she hurt her shoulder. She wasn't sleeping well because you couldn't lie on that side. It was a right shoulder and even if she turned over on her left side, she just couldn't get as comfortable as normally before the surgery. It just impeded her sleep so much. Of course, her everyday activities were affected too, she couldn't shower, or do her hair. She couldn't put on her clothes comfortably. Putting on her bra was just extremely difficult with her right shoulder.

Her complaint was pulling up her pants. She said, once I get my pants up to my thighs and have to put some effort into it to get them all the way up. It really hurt her shoulder. So that was a big deal, whether she had to get her husband to help her out and that's tough. Having to get help to put on your clothes when normally you don't need it. She was definitely flared up and probably had a very acute situation.

But let me back step on that. She did have a degenerative tear, but it was very flared up right now. In other words, it was hot. It wasn't like she had some accident. Because we get some people that on their own before they get to us, they, they flare down when they are flared up. so they are not as as acute as we call it. They are not in as much pain, they can move a little bit better, but the tear is still there and needs to be fixed.

Well, this woman was definitely flared up when she came in, she couldn't pick up her arm very much, and she was having trouble with all that stuff. So one of the first things we will do with these people is we tell them, we need to get that tissue under control, it's just like a cut your skin and you got some bleeding happening, the first thing you got to do, whenever you get a cut on your skin, is to control the bleeding and bandage it up. It's probably going to bleed a little bit throughout that first day, maybe even into the next day, until enough healing occurs, that it stops bleeding and then you just have to baby it for a while so that it scars down and becomes normal again.

Same thing in the shoulder within these tendons. So, we told her is to get a sling, the type of thing that you get if you went to the hospital with a shoulder problem. Just a basic sling one that they sell like at Walmart, or like a CVS or Walgreens, a lot of grocery stores even have them, they shouldn't cost them more than 20 bucks, some are as little as 10 or even less. It doesn't have to be a hardcore sling. Get yourself in that sling and you need to cinch it up really good so that it shoves your shoulder up.

Because what I want to have happen and I'll show people here in the clinic, I need that ball shoved up into the socket so that it's not tensioning the rotator cuff. Because if you don't have that ball shoved up into the socket, then essentially, it's hanging out. Gravity is pulling it down, especially if you have a tear, a full thickness tear, and you are just not going to bring the edges of the tendon together as easily to facilitate healing. So, you need to have that sling on for most of the day.

We tell these people, you can sleep without it, as long as you can get decently comfortable, but during the day, you need to use it and it serves two purposes, that first one that I talked about to bring the ball up into the socket. But the second one is to reduce your usage of it, because automatically when you are in that sling, you are just going to use that arm less, you are going to  have to open the door with the other hand, you are going to  have to not do that chore the same way that you were doing it before. It's also going to tell other people as well that you are hurt, so they'll be more likely to help you out so that you can baby that shoulder and let it flare down.

Once you flare it down, then we are in a position where we can work some of the other muscles and start rolling into…

Phase Two, The Cleanup The Motion Phase.

That's what I call it. When I say clean up the motion, we are looking at the way that all the muscles work together to control the ball and socket joint. Usually there is an imbalance between those two and we have to clean up that motion, clean up that imbalance so that the forces are normalized and you can take pressure off that tendon that was torn. Then you can begin to heal a bit faster.

We also have to look at the shoulder blade, and all the muscles that attach to it and move it around. Because that's a big deal. If your shoulder blade is moving properly, the outer part of the shoulder blades serves as the socket for the ball and socket joint. All those rotator cuff muscles attach on to the shoulder blade and then they connect out through the rotator cuff tendons to the ball part of the joint and they bring them together and stabilize them. We have to make sure that the shoulder blade is moving well.

Then what gives stability to the shoulder blade is the spine, the upper back and the neck. We have to look at the muscles that give stability there and the posture that's going on within all three of those areas, the spine, the shoulder blade, and then the ball and socket joint. We have to clean up the motion. There are some simple logic exercises to do. They need to be done quite repetitively.

Sometimes we need to hang out between the healing phase and the cleanup motion phase for a while. Once the healing phase is pretty much over and there isn't much pain in the shoulder at all except with a few motions. Then the motion is cleaned up. Largely people are learning how to move better, then we can enter the third and final phase.

Phase Three, The Strengthening Phase

This is the longest phase typically, because most of the time people that have this degenerative type of tear, have chronic weakness, they have avoided working out their upper body or they just haven't worked out in such a way that's helpful for their shoulder.

We have to begin undoing a lot of weaknesses that have been going on for years, maybe even decades. Strengthening muscles just happens slowly and just need lots of reps over time. We start out people with some daily exercise and then, as they go gets stronger, we can reduce it to every other day. Then usually it's just a couple times a week as they start maintaining the last kind of lesser reach phase, a fourth phase, if you will, as a maintenance phase.

Which I'll tell people about, but I don't typically see them throughout that process. That's what they keep up on their own. And that maintenance phase is critical, by the way, because if they don't do it, if they don't stay in that maintenance phase. They don't keep up the exercises that they are supposed to, which are usually some sort of overhead lift, some two basic exercises, then they can begin to regress and get their rotator cuff tendon injured again or irritated again.

Those are the three phases, the healing phase, the cleanup the motion phase, and the strengthening phase. Then the bonus extra phase that you should hang out in, is the maintenance phase. But the first three are the ones that we carry people through here in physical therapy all the time.

That’s everything that I wanted to talk to you about for the podcast here. I wanted to answer the question of why a rotator cuff happens, what are all the details surrounding the muscles, the types of full thickness versus partial thickness, acute versus degenerative, and all the reasons that a rotator cuff tear can happen, and then how to go about naturally fixing it.

Just one last thing about the natural fix, we see people with full thickness, degenerative tears here all the time, and they get better. What we know in the research is that, it is possible to fully recover, and maybe not even have your rotator cuff tendon attached again. But to move your arm normally, you can compensate with other muscles. It's my belief that the tendon does actually regenerate and heal. We just don't have solid research for it. Hardly anybody that gets better goes back when they are feeling great and doing everything that they were doing before. That nobody ever says hey, can you go get him another MRI just to see if it's connected or not.

I've never heard of that happening. Maybe it's happened here and there. But I haven't seen any research studies about that. It's just not studied. A lot of people in the medical field will say, Oh, well, it's torn and you are not going to get it back. But we don't have any hard evidence to say that. I think it's really a false statement, but it's a common belief, and it's imparted on patients a lot.

But I've seen it happen here in the clinic over and over again, where people get better, but they don't want to spend the three or four grands to go get another MRI. They just say you know what, I'll pass, I’m back to normal anyway. So, think about that whenever you are considering surgery or considering how to go about fixing your rotator cuff problem.

Anyways, I hope this has been helpful for you. If it has, please share this with somebody that you know needs to listen to this. Somebody else who also has shoulder problems, possibly rotator cuff tear, if you think that this information was helpful for you, I encourage you, actually let me request that you leave a five star review for our podcasts that would really help to get visibility out there, to get more people to learn more about a rotator cuff problem and see other ways to help their shoulder besides medications, injections and surgery there.

There are natural solutions out there for rotator cuff problem. Subscribe to our podcast if you want to keep getting more information about this, I highly encourage that. We put out content every week about different body parts. Right now, we are talking to all about shoulder and neck problems. But please I love the review. I’d love for you to subscribe and share this as well. Thank you and I hope you have the best day.

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Hello El Paso! Welcome to the Stay Healthy El Paso Podcast. My name is Dr. David Middaugh. I'm a physical therapist and I'm the owner of El Paso Manual Physical Therapy.

Today we are going to be talking about herniated discs, bulging discs, and degenerative disc disease and there are other things that happen to discs as well. Specifically, after we go over what is all this stuff and how does it happen? We will also talk about what the treatment options for disc injuries like these are. Let's just get into today's topic.

What is the difference between a herniated disc, a bulging disc, degenerative disc, or a slipped disc? There are all kinds of problems that can happen to discs. At the root of it all is a disc injury. You can get into specifics based on what doctors find, if you have ever had an MRI, if you have had a back problem, maybe you are listening to this right now, because you have a disc problem, and you want to learn more.

You might have looked at your MRI report or your X-ray report. Or you might have talked to the doctor, and they told you about what was going on. They may have used the word, you have a herniated disc, or they told you that you have got a bulging disc, or you have degenerative disc disease. There are all kinds of things that can happen to a disc.

The difference is in a herniated disc, where there is a bubble that comes out and may press against a nerve, it may press against the spinal cord. It's usually just in one section of the spine. Whenever you hear about this happening in the lower back, they can go out directly backwards, towards the middle of the spinal cord, or they can go out to the side and not affect any nerves. Or they can come out halfway between the back and the side where there are some nerves that run out the side of the back.

That can be problematic as well. Bulging disc means there is an entire section of the disk that is wanting to come out. It's being shoved out a bit, but it's not a bubble. It's like a love handle that appears on the disk.

Degenerative disc disease is when the disc itself is degenerating, it's actually becoming injured over time. You might get some hardness that develops inside the disc, there could be cracks in the disc. It's like an old disc, essentially. But you don't have to be old necessarily to get it, and they can get older at one level relative to another level. Which means that you can have degenerative disc disease at L5, for example, but not at L4 or L2, or L3. We have to ask questions about how that got there. And we will ask those questions in a second.

Another common thing that you hear about is a slipped disc. Slipped discs are kind of unicorns in my opinion, they are not really found in medical research. You might find a mention here and there. But as far as what it actually looks like it's not really a thing. The picture that people have, when referring to a slipped disc, is that the disc actually slides out of position, and detaches from the bones.

What most people don't understand is that the attachment between a disc and the bone, the vertebrae, the spine bones, it is extremely stuck. There is no way it's going to slip out. It just doesn't shove out one way or the other as a whole, it might herniate. You might get problems with the disk, but to get it to detach from the bone., I've never seen that happen or heard of that happening. Slip disc, I think is kind of a misnomer. It's not a good term to use, but it's still commonly used out in the in the medical field.

Now, why do these problems happen? And are there different reasons for each one, and in my opinion, it's usually the same similar set of problems. It's set up different types of disc injuries. It just depends on your genetics. It depends on what your spine is predisposed to, getting the type of injury that is predisposed to. If you have parents that had similar disk problems, and that's probably why you are having that.

In small cases, it can be some specific activity that you repetitively do that sets you up for this type of problem. But they all have the same root problem, there is usually a muscle imbalance between the muscles that stabilize the spine. Now, we are going to go somewhat deep here, into the root of why a disc problem happens. So follow me and pause if you need to think about the words that I'm using for a second, I'll try to keep it as simple as possible.

In a lower back, and we are talking about the lumbar spine, the lower back. You have three main muscle groups that create all this stability in your lower back. One is the back erectors, these are the muscles that run up and down the sides of your spine. On the backside is your abdominals. Of course, the abdominals are on the front, but they wrap around and attach through tendons to the spine on the back, and they also attach to the pelvis, the bones that the spine connect to at the bottom.

Then the third group would be your hip flexors, specifically your psoas muscle, which is a hip flexor, and it runs from your thigh bone, the top part of your thigh bone deep in your hip, and it comes through the front over into the pelvis and attaches up into the lumbar spine.

Between these three muscle groups, you have to have proper balance so that your spine can stay in the best position possible so that the discs can work properly. Now if you have an imbalance and your spine doesn't stabilize properly, then you are going to present eventually with one of these problems that we've talked about. Either a herniated disc, a bulging disc, or some sort of disc problem. It's just a matter of time.

Usually the thing with discs is, they are super resilient structures. They are tough. They are hard to dissect. When we have cadaver dissections in physical therapy school, those things are super hard, you can't cut through them very easily, it's actually easier to cut through the bone than it is to cut through the disk. And disk tissues are designed to be shock absorbers. So they contribute to your spine working like a spring.

Now, if you google a picture of the spine, or if you by chance can see a skeleton around you or something like that. I'm in the clinic right now, so I'm looking at the skeleton. You may not be but if you just pull up a picture of a spine, or if you think about it, if you have a pretty good memory of what they look like. All the bones stacked right on top of each other right from the tailbone. Then you have the 5 lumbar vertebrae, that all stacked on top of each other. Then you have 12 thoracic spine vertebrae that all stack up on top of each other. And then you have the neck, the cervical vertebrae that all stack up on top of each other.

Our bodies are designed to stack, we are bipedal. In other words, we walk on our two feet versus dogs or cats or cows, they walk on four feet. Their spinal structures are different than ours, they have similar components, but the way that they are designed to absorb the forces of gravity and be able to get around, there are small variations that allow us as humans to be able to stack vertically.

Now the problem comes going back to that muscle imbalance. If you have an imbalance, the one of the first things that tends to happen is the lumbar spine, the low back begins to lose its position. You'll start to curve in your back too much. You are no longer stacked vertically, and you start to curve too much. Now what I'm telling you right now is a bit controversial in the medical field, because there are all this argument about how much curvature should you have in your lower back, same thing for the neck and mid back. But I don't think that there is one specific number that everybody should fit.

Everybody is a little bit different. And depending on your body shape, if you got a smaller waist or bigger hips, or if you are pretty straight, or whatever your shape is, there are small variations with everybody. But I think the general rule to follow is that you should be pretty vertical in your low back. If you start to curve too much, then your spine starts to bend in the middle of your low back. And if you think of a spring, if you bend the spring, it wants to come back to its straight up and down position. But if you hold it in a bent position, and then you make it absorb forces, it's only a matter of time before that metal spring begins to crack or break or not work properly.

If your spine stays bent too much, what tends to give out first is a disc. The disc can take a long time to get injured, but you'll begin to see a disc bulge or herniation. Over time, you can get degenerative disc disease, and it can be painful. But that's how disc injuries are set up.

Now, treating disc injuries is a whole different ballgame. We have to figure out what the source of the problem is. Is it truly just as muscle imbalance or other things? Is there weight to account for? If it's a female, have they been pregnant? How many times if you had a C-section? Because you are pregnant, they probably did cut open your abs and you probably lost strength to your abdominals, which is one of those stabilizing muscle groups.

Now I've got to ask the question, did you ever get that strength back in your spine, if it's curved? If it's too curved, what is too curved?

That's hard to determine. Even in the medical field, we don't know. We have people looking at x-rays, and actually measuring angles and everything. It varies from individual to individual because there are so many things to look at.

What will feel like if you have a disc herniation? It tends to feel like an achyness in the lower back, it can also set off muscle spasms. A true disc problem tends to generate pain right in the middle of the back, but you can have spots of pain that appear in different areas. It might change from side to side. Sometimes the glutes can feel painful as well. You might even have pain that runs down your leg. Because sciatica is a very common side effect of a herniated disc problem.

There are different versions of nerve pain that run down your leg Sciatica is one, there is another one called lumbar nerve ridiculous apathy. That's when you have a pressure from one of those discs that's pushing on a nerve, and it sends pain down into the leg. It could go all the way to your foot.

I've felt a mild sensation of that, and I remember feeling it down into my right big toe. It was painful. It was insane. So I felt it myself. But I've had plenty of patients coming in that describe the exact pathway of the nerve that's involved. We can usually trace it back to a loose disc in their spine because it's injured.

I just mentioned those words loose disc in the spine. Whenever I'm checking a client that has a potential disc problem. I actually look at the stability of every single level of their spine. This is important because what we should find is that it's uniform that pretty much every level of the lumbar spine of the lower back moves about the same. There are small variations. But there is a general normal amount of motion that each one should have.

What I tend to find in these people, that have very arched backs, they have some sort of history of a disc problem is that where their back hurts the most. The disc between the bones and in that level of the spine, tend to be loose in the bones that attached to the disc, and will move excessively. They'll move way too much, and if I poke in that area that people will typically say, Yep, you found the spot. That's it. That's where my back hurts all the time. It just doesn't feel very good for me to poke on there. But that's what I've got to do to figure out the problem.

Other signs that people tell us is standing for too long, doesn't feel good. They feel like they need to sit down to get relief. They will lean on things, lean on shopping carts, lean on tables or countertops to take pressure off their back. They are doing that subconsciously, they don't know they are taking pressure off their back always. But it will just feel good to lean out over this way. It takes pressure off their disk.

Another telltale sign of a disk problem is people that have trouble sleeping at night because of this back pain. They usually dread turning over in bed, if they go to twist and turn over to lay from one side to the other side or move on to their back or their tummy. It tends to kill them quite a bit. That's a more extreme example. But you do see that general twisting motions tend to not feel good. People who have children, for example, getting kids in and out of their car seats can be painful for them. Doing laundry, having to twist in awkward positions to get into a washing machine, or a dish washing machine as well.

That tends to be pretty uncomfortable on a back problem. They tend to not be able to stay bent over for any period of time. They usually are decently flexible, they can reach their legs or toes, even sometimes they even reach the floor. They don't tend to have a big flexibility problem. They may not be the most flexible person in the world either, but they don't report that they are inflexible. They have pain though, if they are staying in a bent over position for a long time, or if they are having to lean over and hold it for a while.

Some of these people tend to feel better when they lie on their stomach. It relieves your back problem versus lying on their back. They don't like it too much, especially when their legs are straight. They feel like they are very uncomfortable. When they lay on their back and their legs are straight, they have to bend them up, and bend their knees so that they can take pressure off their back.

Notice I keep saying take pressure off the back. That's really what is causing the problem, there is excessive pressure because the spine is bent and it's aggravating the disc problem. So if you get that excessive rotation that happens in the spine because it loosens if you are bent too far, and you walk like that, you live like that, you move like that, you start to rotate too much at that level of the spine, wherever the disc injury is at and it creates an instability at that disc over time. That's typically what sets up people for a bulge, or herniation. Or some people don't get that, they get degeneration over time.

Now, a big question that people frequently ask, whenever they come in for help with a disc problem is, can my disc heal? It's very confusing out there. And what I want to tell you is there is some research out there that shows that disc tissue can heal. There is no research out there that I've found conclusively that says that discs don't heal. What the research does say is that people with disc problems tend to not improve their discs. But that doesn't mean that there isn’t something out there that can make them heal.

There is evidence of discs healing, so I hope that's not too confusing. Just to say this one more time, there is no research that shows a disc can't heal, but there is research that disc can heal. And there is research that people that tend to have a disc problem basically tend to not do the right things to get better. So there is evidence that people don't get better is what it is.

Now, on the topic of disc healing, what we know is that it takes about a year for discs to heal, and it is possible to put scar tissue down in a injured disc area. As long as the disc isn’t injured so severely that it's pushing on a nerve, it tends to get better without surgery.

If you think that you have this problem where its pushing on nerve because it's so painful. That might be the case but in people that that actually need surgery, the pain will be debilitating. I mean to the point where they cannot move, they cannot function. In very extreme cases, they are having accidents like a bowel and bladder accidents, like they are pooping and peeing themselves. I have seen a couple of those cases and they don't look very dramatic. What they tend to say is I've made it to the bathroom, but it's real close. There has been sometimes where I actually get myself a bit dirty. But I usually am able to hold it longer and get to the bathroom just fine.

If that's happening, if you have those kinds of symptoms, if you got debilitating pain down your leg, you need to go to the doctor and get a MRI, likely they'll tell you what to do, you actually might need a surgery. But if it's just back pain, and I say just back pain, it could be very painful back pain, but you are not having any bladder problems, or having debilitating pain that doesn't let you even stand up or walk. It could still be limiting you from sleeping enough at night. It may not let you be comfortable when you are driving, you may find that you need pain medication and extra help from the doctor. Those types of back situations almost always can get better without having to have a surgery.

Now, let's talk about what the treatment options are for a disc problem.

The most common place that people start, whenever they visit their doctor for a disc problem is, they get offered pain medications. This could be muscle relaxers, it might be strong heavy-duty pain medications, or the doctor might even recommend over the counter pain medications. And many times, that's enough to take the edge off so that people can function, work, take care of their family and kids, and get them through a flare up.

But if this back problem isn't handled properly so that it's getting better for the long term, it's usually just a matter of time before it flares up again. You have to make sure that you take the proper steps to manage this problem for the long term.

Other things that doctors will recommend are back support braces, they sell them at a drugstore, and sometimes even grocery stores have them, or you can get them online. There are special ones that you can cinch down real tight. Those tend to be pretty helpful for disc problems, but they are short sighted, they don't fix the problem for the long term. You have got to fix that muscle imbalance.

Usually there is some weakness within the muscle groups that stabilize the spine. There might be some movement problem as well. There is usually a slew of problems that all come together to create a disc problem. But wearing a back brace might allow you to not take as much pain medication.

The next thing doctors will often offer are injections for your back. They will inject corticosteroid pain medications, pain medication and an anti-inflammatory medication straight into your back so that you can have less pain and they are pretty effective. Most people report having immense pain relief for up to a few months. The thing is, they don't last forever, some people will flare down and they get a longer benefit of pain relief. They might be good for six months or a year, but we often hear the story where people say, yeah, I've had this back problem for almost 10 years now. I usually can rest it off, I usually can do some stretches, I usually can go to the doctor. If it's really bad. They'll give me an injection and then I'm good for another six months, or another year and then it just keeps happening over and over as the years go by.

They keep self-managing with injections, with pain medication, and with exercise that stretches those kinds of things. But meanwhile, their muscles aren't getting more in balance, they are actually getting worse. And they are working on a disc injury, on a herniated disc, or a bulging disc, or they are creating degenerative disc disease in their spine. It's just a matter of time before it starts to really be bad to the point where it can be debilitating. You have to be careful with those injections as well. Use them as short-term pain relief, but make sure you work on a plan for the long term.

There are a couple of different surgeries that are commonly done. There are more than these two that I'm going to mention, but these two are the most common. The first one is what's called discectomy. This is the minimally invasive surgery that's done out there. And the reason why they say that is because they just make one or two small incisions, and you actually leave the office the same day. You don't have to stay overnight, usually in the hospital, and they can sometimes put a Band-Aid over the incision and that's all you need to heal from the incision site. That's why they call it minimally invasive.

But they do go all the way down deep into your spine right where the disc is at. And they cut off the chunk that's bulging, or they shave it down, or they remove the part that's herniated in the clean up your disk so that it's more normal shaped. They are taking out disk tissue.

If you have that really severe pain that's going down your leg and you are having tons of trouble, it might be what you need. But you got to be careful in thinking that this is going to be the last time you are going to deal with this back problem. Because if you haven't worked on your muscles, your strength, the way that you move, fix the underlying root problem for your back, then it's likely going to come back. We often see people that have had multiple discectomies.

I had a client in fact, who already had two and was on his way to have in his third. His surgeon was recommending a third discectomy in his back. But he didn't want to do that again, because obviously the first two hadn't worked. All this is within a year and a half timeframe from when he had his first one. He came to me to try doing an alternative physical therapy. And he had done physical therapy as well. But he had done a type of physical therapy that had a different kind of focus than what we have here.

Here at our clinic, we figured out his muscle imbalance, we figured out what joints were stiff, which ones needed to be stabilized, went through the whole process. And by the end of his treatment plan, which we saw him for about four months. He actually was weightlifting. With a barbell, one of those big long weight bars. With 135 pounds on his back, we loaded up his spine. And the reason why we got to that point was a cool thing that happens in discs in your back and really all tissues in the body as they adapt to forces.

We got this guy to the point where his back was no longer flared up. He was saying, I don't have any pain, I feel fantastic. I can bend over, I can stand, I can walk, I can even jog a little bit. We really tested him before we put any weight on him, and he's a big guy. He used to play football. He's has a pretty big frame. So he's able to take some weightlifting just fine. You could tell his body is built for it. We put a little bit of weight on his body and we had him do some squats with like 10 pounds, and then 20 pounds, and we worked his way up gradually. He sped through it and I was making sure that he was safe and that no adverse reactions were happening.

We worked on this form and his technique, and he had corrected his muscle imbalance to the point where he could squat and load his spine so that his disks can feel that pressure and the cells inside the disks can detect it and tell each other to get stronger and denser so that they get healthier.

Just like your skin will get calluses, if you are weightlifting or doing yard work, or house work that makes your skin get calluses around your feet as well. People get calluses on their feet all the time. That's the skins response to extra forces that's put on it so that it protects itself and makes it so that it's safe to do that activity again, without tearing your skin. If you get callus, that's good, because you didn't break your skin or get a blister, it wasn't too much activity too fast, because that's what will break your skin. Obviously, it was a tolerable amount for the skin.

We do the same thing in the back if we if we load the spine. Once it's all healthy, in a way that's tolerable, little by little over time. You can work your way up to where you are actually creating a protective amount of strengthening through the disk, but you have to lift weights to do that.

I just want you to be careful if you are out there and you got a disc problem. Please don't jump straight into weightlifting, like the story that I told you, you have to take it a step at a time, get expert help, make sure you are working with somebody who knows what they are doing, how to fix these muscle imbalances that we are talking about.

Don't jump straight into it. I'd be careful to working with a personal trainer as well, just because depending on their background, there are some trainers out there that are pretty good at what they do, but they may not have a full understanding of all the anatomy and the physiology. and the way that all this stuff works together. Their version of a squat may not be what you need. So you got to make sure you find the right kind of help to get to what you want to do.

That's just one story. I've got tons of other stories of people with severe disc injuries that are doing just fine now, even lifting pretty heavyweights.

Now, with surgery, and we were talking about the discectomy, the second most common surgery, if discectomy is not an option, or they've already tried them, and they haven't worked. The next most common surgery is a spine fusion.

When they do this, there are different ways they do it. But the most common one is where they put rods and screws into the bones of the spine to maintain the space of the disk and offload the disc, but at the loss of being able to move at that spine, that's why they call it a fusion. So those bones are essentially fused together through the hardware that's installed and it no longer allows movement at that level of the spine. It preserves the nerves and allows the pain to go away.

It's a miracle surgery, it really can make a huge difference. When done for the right person. There are people that lose the ability to walk because of a spine problem. And once they get a fusion done, and they can walk again because the nerves had the pressure taken off and they are normal.

If it's that bad and you need a spinal fusion surgery, then of course, consult your doctor and let them make that determination. But there are natural ways to take pressure off your discs using your own body, and there are ways to maintain that over the long term. And as we discussed, with weightlifting you can make your discs more dense.

My advice to you is, if you are dealing with a suspected disc problem, get started on getting help early, don't let it go on forever, don't let it fester and get worse and worse and begin to affect other things. Because it will create a nightmare situation for you. You don't want to have multiple surgeries or any surgeries for that matter. You don't want to have to be getting injections all the time and relying on pain medications, having to rely on putting on a brace all the time. You don't want to be defined by your back problem. You don’t want to be that person that is always talking about how much their back is bothering them.

I'm sure you'd much rather enjoy your work, your family, your life and be able to do the things that you want without your back bothering you.

So lastly, the next most common treatment for back problems is physical therapy. There are different types of physical therapy. I just wanted to highlight what we do here in the clinic at El Paso Manual Physical Therapy. Our specialty is manual physical therapy.

What that means is by hand, we spend a lot of “hands on” time with every client. And because we are by hand, moving every bone in the spine and checking it to make sure that it's moving properly. We look at the soft tissue, in other words, the muscles, ligaments, tendons, nerves, that might be affecting the situation.

We take a holistic approach when we are looking at the entire body, not just low back. Because oftentimes there is a hip problem that's feeding into the back problem. There is an upper back problem that's creating more pressure in the lower back, and even down into the knees, the lower legs, ankle and feet, we need to look at that as well. When you talk about the way that you are walking, about the way that you are running, or doing any other activity, we need to go in depth, and make sure that we address you as a whole person so that your back problem can get better for the long term and stay better.

That way you have the most control over your back, you know what to do, you know how to keep it healthy. If it ever starts to flare up on you, you know exactly what you need to get back to doing.

Physical therapy is amazing for back problems. You just got to make sure you find the right physical therapist that fits your needs. And that might just take a chance or two. You have to try different people, different companies and see what you like the best. There are different types of physical therapy clinics out there. And by and large, most of them focus on helping people after surgery. So if you have had a knee replacement or a back fusion, like we talked about a discectomy. Like we talked about meniscectomy and your knee, that's another type of surgery similar to a discectomy.

Going to these clinics that handle a lot of cases after surgery is a great idea. But if you haven't had a surgery, then going to a clinic that tends to see more cases that have just had surgery might not be the best idea, because they are just not going to be best suited to help you out. You might look out and find somebody that's great. But more often than not, you might end up doing very similar exercises to the people that just had surgery because that's how their systems are. H

Here at El Paso Manual Physical Therapy, we rarely see any surgical cases. We tend to help people that are just looking to avoid surgery. They haven't had surgery recently in the past, or they might have, and they just don't want the second or third surgery. But we are looking at people without them having had a surgery, so we are trying to fix a problem from getting worse, to the point where they need injections, they need to be relying on pain medications, and need a surgery. So be sure to do your research when looking for the right kind of help.

Thanks for listening guys. I hope this was helpful for you. I hope you know all about disc problem now and you know the best information so that you can make the best decision about how to move forward in helping your discs heal for the long term. Have a wonderful day. Bye.

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