What’s the difference between a ligament and a tendon?

Ligament_tendonI am frequently asked this question by my patients and thought it would be useful to provide a blog article about it.

The simplest explanation is that a ligament is a connective tissue that connects one bone to another bone.  Conversely, a tendon connects a muscle to a bone.

Both are made of collagen fibres but the layout of those fibres are different between the two.  In a tendon, the fibres are laid in parallel, allowing for more elasticity which if you think about the way muscles work and the amount of movement involved, this makes them more suited to connecting the muscle to the bone. The fibres in ligaments however are laid in a criss-cross fashion to create structural stability to the ligament and ultimately to support, stabilize and strengthen joints.

Since ligaments are strong and rigid by nature, their primary role is to keep a joint stable.  However,  strains and sudden forces can cause them to rupture and tear which is a common sports injury.  The severity of the injury will depend on how significantly the fibres are torn.  Ligaments are poorly supplied with blood so they heal very slowly and sometimes come permanent.  Also, if a ligament is stretched past a certain point, it can result in the ligament never returning to its original state.  This explains why if you have ever had a severe ankle sprain, very often you become a repeat ‘sprainer’.

Similarly when tendons are over strained, they can become damaged and even snap. A partially torn tendon can cause swelling and discomfort but can be healed over time.  A complete tear in a tendon can cause total loss of function and movement and may even result in permanent damage.  The traditional treatment for an injured tendon would be to follow the R.I.C.E principle initially of rest, ice, compression and elevation…however, ice is a bit of a controversial topic in the rehab realm lately.   My recommendation is that if you can truly see some swelling then go ahead and apply ice for the first 2 days.  If the injury is more serious a splint may be necessary in order to aid the healing process whether that be through a proper athletic tape job or the use of supports or braces.

It can be difficult to be able to distinguish between a ligament and tendon injury and sometimes the only way to do this will be to visit your doctor, chiropractor or physiotherapist who can perform specific orthopedic tests or order and X-ray or ultrasound test to confirm the diagnosis if necessary.

The most critical thing is to make sure you do not leave any injury untreated to prevent further damage.  And don’t be a hero and try to play through an injury!  Prompt and proper treatment with manual techniques, modalities like ultrasound or laser therapy, supports and taping, and progressive exercises will get you back in the game sooner!

Until next time,

Dr. Keith

Frozen Shoulder – It’s Not A Winter Injury!

Recently, I’ve had a number of new patients suffering with varying degrees of frozen shoulder.

You may have heard the term ‘frozen shoulder’ from time to time perhaps amongst your family and friends or maybe your colleagues at work.  My own sister developed it last year after a ski accident at Mount Tremblant.  Maybe you have suffered through frozen shoulder (aka adhesive capsulitis) yourself at some point.

Well, if you’re not sure you probably haven’t had it, because those that have will certainly know and remember the unpleasant experience.

It is a very painful shoulder with restricted range of motion due to inflammation and thickening of the shoulder capsule.  If not treated properly, most people go through a long recovery process if not treated properly and your doctor may have even told you that it could take up to 2 years to heal!

The strange thing about frozen shoulder is that it can sometimes develop totally out of the blue from no apparent reason.  Typically it affects middle-agers, and interestingly enough, in females more than men.  Those who have diabetes or other endocrine disorders are also more susceptible.  Although it can frequently occur after you have suffered a separate shoulder injury, I often have patients who say they simply woke up one day with a bit of pain and since then it has slowly gotten more painful while the shoulder movement has progressively decreased.  A person will usually say that reaching up or behind the back is difficult and painful.  This means day to day activities like washing your hair or unclasping your bra strap is challenging or undoable.

Frozen shoulder is usually diagnosed through a physical exam by a health care provider who will take into account your history and symptoms and in some cases it may be necessary to order an x-ray, ultrasound or MRI via your family physician to rule out any other possible shoulder issues like arthritis or a tear in the rotator cuff.

So what’s going on inside the joint?  In frozen shoulder, the shoulder capsule becomes inflamed, thickens and becomes tight. Stiff bands of tissue called adhesions develop. In many cases, there is also less synovial fluid in the joint to keep it lubricated.

The hallmark sign of this condition is being unable to move your shoulder either on your own or with the help of someone else.  Classically, it develops in three stages:


In the”freezing” stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.


Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the “frozen” stage, daily activities may be very difficult.


Shoulder motion slowly improves during the “thawing” stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

So what can you do about your Frozen Shoulder?

The recovery process is not easy by any means.

Conventional treatment has typically been taking non-steroidal anti-inflammatory drugs (NSAIDS) along with intense physical therapy….probably what your family doctor advised if you went to see him/her first.

Corticosteroids may also be used to control pain and increase movement of the shoulder.  The relief from steroid injections is often welcomed by the shoulder sufferer but I’ve seen the results vary from doing nothing at all to having pain relief for a few weeks and then going back to square one.  I consider it a band aid solution that needs to be used in conjunction with additional therapy for the most benefit.

In worst case scenarios surgery may be used to get rid of the scar tissue, but even then, physical therapy is needed afterwards to help restore the ROM.

What I find to be an effective and non-invasive alternative is the combined treatments of BIOFLEX laser therapy, electroacupuncture, ROM exercises and manual therapy can help break down scar tissue and restore normal, tensile tissue in the shoulder. Treatments can also help reduce or eliminate the chronic inflammation associated with frozen shoulder.

Frozen shoulder is not something you want to develop so make sure you take care of your shoulder and get treatment for an injured shoulder as soon as possible.

We’re more than happy to help you on your road to recovery so that you can get better quickly and return to your normal daily living sooner.

Got questions?  Feel free to contact your friendly neighbourhood Richmond Hill chiropractor!  I’m just an e-mail or phone call away!

Dr. Keith

Pain Medication vs. Acupuncture for Sports Injuries

When it comes to sports injuries, I’ve been on both sides of the fence; being the injured athlete in pain and disabled and being the doctor/therapist treating the athlete.

It’s certainly no fun to be hurt.  And it’s also no fun to be sidelined from the sport you love because of pain and injury.  What do you do?

For many athletes, whether they are a professional, amateur or weekend warrior, the common response is to open up the cabinet and reach for the pain medication.  It could be the over-the counter variety like Tylenol, Advil, Aleve, etc, or it could be prescription type like Tylenol#3, Oxycontin or Percocet from your medical doctor.

Now I’m not saying it’s wrong to take pain medications…there is a time and place for these.  But I will say that they should not be relied on solely to help alleviate pain and restore the injured athlete.

This is where acupuncture can play a vital role in the treatment of athletic injuries.  Because acupuncture can not only relieve pain by desensitizing nerve endings and reducing swelling and inflammation but also stimulating your body’s healing mechanisms to repair damaged tissue.

What are the important differences between acupuncture therapy and pharmaceutical therapy?  Acupuncture works at the level of the injured tissue, the spinal cord level to block pain signals and the brain level to change the perception of pain.  Importantly, it starts by fixing the damage first and as the tissue heals, the pain naturally subsides.

This occurs because inserting an acupuncture needle in the area of an injury stimulates the immune system and blood circulation resulting in more oxygen, nutrients and immune repair cells delivered to the injury site.

In contrast, pain medications can block the pain signal at the spinal cord level or brain centres to quickly take away the sensation of pain, but the tissue damage is still waiting for the supply of nutrients and oxygen that is required for healing.

The danger then is for athletes to use pain meds or even worse, steroid injections, to suppress the pain.  They then return too quickly to training and competition and the tissue damage becomes more severe.  The athlete is lulled into a false sense of belief that he is ‘ok’ when he truly is not and soon an acute injury become a chronic one that puts him/her out of action for an even longer period of time.

Who would’ve thought that these little needles could do so much?

Dr. Keith


Shoulder Pain from Shoulder Impingement

“How did I get a shoulder impingement, doc?”

This was the question asked to me yesterday by a patient with shoulder pain after I had run through an assessment on his shoulder.
He had developed an acute case of shoulder pain after reaching down to grab and pull a garden hose during backyard clean up on the weekend.  The pain was debilitating as he described it and he could barely lift his arm higher than about 20 degrees for the first two days.  And sleeping has been nearly impossible.  However, this morning after taking a shower, inexplicably the pain seemed to ease up considerably and his range of motion was almost completely full with pain mainly when the shoulder was abducted to 90 degrees and beyond.

After a bit of questioning and having this patient go through a battery of orthopedic and functional tests, I told his gentleman that his pain was due to shoulder impingement…which elicited the question at the top of this blog post!

Shoulder impingement is a very common cause of shoulder pain.  It’s where the rotator cuff tendon is pinched or compressed underneath the lateral most part of your shoulder blade called the acromion.

It occurs commonly in middle-age (my patient is 50), but can affect anyone who engages in overhead activities (my patient has embarked on an exercise, weight-lifting program to lose weight and get healthier over the past 6 months).  The impingement pain can be felt at the front or back of the shoulder depending on how the impingement is occurring.

There is only a small amount of space between the acromion and the upper part of your humerus, which means there is really just enough room for the rotator cuff tendon to glide through as the shoulder moves your arm around.  The tendon can become more susceptible to impingement when something causes this space to narrow down further.  For example, muscle imbalance, shoulder joint instability, tendinopathy, spurs and labrum injury can all result in impingement by reducing clearance.

Extremely common is repetitive microtrauma associated with overhead movements.  If you are involved in sports like swimming, volleyball, baseball, tennis or work in occupations like construction, you are susceptible to shoulder pain resulting from shoulder impingment.

Once impingement is in place, the repetitive pinching of the affected tendon can lead to irritation and inflammation of the rotator cuff tendon.  This in turn can cause the tendon to thicken which can lead to worsened impingement.  It becomes a vicious cycle!

So what can you do about it?

  1. First you need to avoid the aggravating motions…you will need to stop playing your sport for a little while or somehow work around the injury while doing whatever it is that is preventing the tendon from healing.  This is probably the hardest thing for people to do but is an absolute necessity if you want to correct the problem.
  2. Identify the cause of the impingement…you may need to see a qualified health professional for this.  Someone like a chiropractor, physiotherapist, athletic trainer or sports medicine doc.
  3. Get some specialized treatment for the shoulder…soft tissue work, laser therapy, acupuncture, ultrasound…these will all enhance your recovery by improving blood flow, reducing tissue tension and decreasing inflammation and pain.
  4. Religiously work on postural improvement and correcting muscle imbalances…this will fix the poor biomechanics that contribute to reduced clearance for your rotator cuff tendon.  If you can achieve this, the likelihood of the injury recurring is significantly reduced.  Which means you can play your sport or get back to work again for the long haul!

In the case of my patient who asked me how he got shoulder impingement, the answer was fairly simple.  He was a middle-age man who had been relatively sedentary for the past 20 years, had poor posture, and embarked on a heavy weight lifting program to get in shape.  The good news is that over the past 6 months he has lost a considerable amount of weight.  The flip side is that his shoulder pain may hinder further progress…but we’re working on that now!

Got questions?  Feel free to contact your friendly neighbourhood Richmond Hill chiropractor!  I’m just an e-mail or phone call away!

Dr. Keith