372 | Rotator Cuff Tears: What To Do For Shoulder Pain

[00:00:05] [SPEAKER_01]: Welcome to the Optimal Body Podcast. I'm Dr. Jen.

[00:00:08] [SPEAKER_00]: And I'm Dr. Dom, and we are doctors of physical therapy bringing you the body tips and physical

[00:00:13] [SPEAKER_00]: therapy pearls of wisdom to help you begin to understand your body, relieve your pains

[00:00:17] [SPEAKER_01]: and restrictions, and answer your questions. Along with expert guests, our goal of the

[00:00:21] [SPEAKER_01]: Optimal Body Podcast is really to help you discover what optimal means within

[00:00:26] [SPEAKER_01]: your own body. Let's dive in!

[00:00:28] [SPEAKER_02]: So we were talking about the Rotator Cuff. Now, we have done a podcast episode actually

[00:00:33] [SPEAKER_02]: a long time ago when we first started this podcast. So we just want to revisit it, maybe

[00:00:39] [SPEAKER_02]: bring up a couple new research articles that are come out and what you should know, but

[00:00:45] [SPEAKER_02]: really provide you with the exercises that we think you should be focusing on when you're

[00:00:49] [SPEAKER_02]: going through your rehab protocol.

[00:00:51] [SPEAKER_00]: So first of all, what is the Rotator Cuff? We talk about it as if it's one thing,

[00:00:56] [SPEAKER_00]: but the Rotator Cuff is actually four muscles. Often we call them the SITS muscles, SITS plural

[00:01:04] [SPEAKER_00]: because it's the supraspinatus, the infraspinatus, the teres minor and the sub scapularis.

[00:01:12] [SPEAKER_00]: Not that you need to remember those, but essentially what these four muscles do

[00:01:17] [SPEAKER_00]: are their primary actions are to externally rotate the arm, internally rotate the arm

[00:01:23] [SPEAKER_00]: and help with initial elevation of the humeral head or this big long arm bone that we have

[00:01:30] [SPEAKER_00]: when we flex our arm overhead. Those are the main actions, but as they work together,

[00:01:37] [SPEAKER_00]: one of their main purposes is to keep the humeral head centered in the socket. It's a

[00:01:44] [SPEAKER_00]: ball and socket joint and often when a lot of our other big muscles are pulling on our arm

[00:01:49] [SPEAKER_00]: it wants to tug around on that humeral head and the Rotator Cuff muscles are good at helping keep

[00:01:56] [SPEAKER_00]: that centered in the joint.

[00:01:57] [SPEAKER_02]: Yeah, and because we don't have a lot of muscles underneath necessarily or we have a lot of our

[00:02:03] [SPEAKER_02]: ligaments, tendons, everything is kind of crossing the front back and top of the shoulder,

[00:02:07] [SPEAKER_02]: those Rotator Cuffs are really playing a role in your shoulder stability and I think

[00:02:12] [SPEAKER_02]: you'll hear that a lot. These Rotator Cuffs provide the stability of your shoulder

[00:02:16] [SPEAKER_02]: and so when we think of rehabbing our Rotator Cuff then we're looking at what are the stability

[00:02:22] [SPEAKER_02]: exercises that I'm going to use to help my shoulder and though we agree there's a lot of great

[00:02:28] [SPEAKER_02]: stability exercises that kind of progress in the overload of strengthening those muscles,

[00:02:34] [SPEAKER_02]: we also want to look at the bigger picture and why might that be happening and what more can

[00:02:40] [SPEAKER_02]: we do. So we're going to really you know be talking about that but

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[00:04:09] [SPEAKER_02]: when it comes to like kind of feeling that rotator cuff injury this is where it can like well it's

[00:04:15] [SPEAKER_02]: is it impingement is it super spinatus impingement is it just irritation of the shoulder a lot

[00:04:22] [SPEAKER_02]: of times we say that it's within this painful arc right maybe our shoulder blade isn't moving

[00:04:29] [SPEAKER_02]: quite as nicely with our entire shoulder and so we get this pinching sensation i would not correlate

[00:04:36] [SPEAKER_02]: this with cracking and popping necessarily that you're hearing if that is not associated with pain

[00:04:43] [SPEAKER_02]: if you're getting we've done i believe an episode on shoulder cracking and popping before but in

[00:04:48] [SPEAKER_02]: general joint noises are totally normal especially i mean we just have so much going on around

[00:04:54] [SPEAKER_02]: the shoulder so don't think of like that as rotator cuff injury um pain we're looking at symptoms

[00:05:02] [SPEAKER_02]: we're looking at the symptoms of pain that you're feeling traditionally with exercises usually with

[00:05:07] [SPEAKER_02]: overhead exercises or overhead reaching for something or just trying to lift your arm forward or out to

[00:05:13] [SPEAKER_02]: the side that's usually when we're getting those symptoms of rotator cuff and you bring up a good

[00:05:17] [SPEAKER_00]: point because there are four rotator cuff muscles you can have like so i tore my rotator cuff

[00:05:24] [SPEAKER_00]: but what does that even mean you know there's four muscles often when we're talking about

[00:05:29] [SPEAKER_00]: injury or tearing or impingement the one that gets brought up the most is the super spinatus

[00:05:34] [SPEAKER_00]: muscle and there's within any if any of the muscles are damaged there's all the different

[00:05:39] [SPEAKER_00]: degrees of the rotator cuff tear as well so really figuring out exactly what is torn what

[00:05:47] [SPEAKER_00]: grade or what level is the tear and then how do we approach it like that's a big component to

[00:05:52] [SPEAKER_00]: figuring out the best course for rehab i've actually torn a rotator cuff muscle before

[00:05:56] [SPEAKER_00]: uh funny enough and based on some of the research we talk about i wouldn't be surprised if we

[00:06:02] [SPEAKER_00]: image both of my shoulders and notice that i have tears of some sort in my rotator cuff muscle but

[00:06:08] [SPEAKER_00]: when i did it and this is very common for people who tear it i was skipping rocks

[00:06:15] [SPEAKER_00]: at the north the north shore lake superior in minnesota with a friend and i was just kind

[00:06:21] [SPEAKER_00]: of flicking and throwing these rocks sidearm just like nonchalant not worried about what i

[00:06:25] [SPEAKER_00]: was doing and i threw it in my arm it was so weird i threw it at my arm just went dead like

[00:06:30] [SPEAKER_00]: across my body and i was like oh my gosh and immediately couldn't couldn't even lift my

[00:06:36] [SPEAKER_00]: arm you know very far away from my body the next day or even that night like not thinking i went to

[00:06:44] [SPEAKER_00]: like try and get something out of the fridge and just had that really sharp pain in the front of

[00:06:48] [SPEAKER_00]: my shoulder ended up getting an image and they they said on the MRI when there's tears in a tissue

[00:06:54] [SPEAKER_00]: it doesn't like it doesn't spell it out for you and say tear or torn rotator cuff it appears more as

[00:07:01] [SPEAKER_00]: like what they call interference so the tissues don't look super smooth the light or essentially

[00:07:07] [SPEAKER_00]: what the machine is showing in the picture looks kind of scattered and they said well based on

[00:07:12] [SPEAKER_00]: what we're seeing there's a lot of interference here you probably have a tear in your rotator cuff

[00:07:17] [SPEAKER_00]: but yeah i didn't do anything other than conservative treatment uh at that point i wasn't

[00:07:23] [SPEAKER_00]: even a physical therapist i didn't know i was going into this this was before before college even and

[00:07:28] [SPEAKER_00]: yeah got back to full activity full everything haven't had any major shoulder issues since then

[00:07:34] [SPEAKER_00]: that is kind of congruent with what we see in images uh there was a study that looked at people

[00:07:40] [SPEAKER_00]: over age 50 and between 20 and 25 percent of people can have a full to a partial to a full

[00:07:48] [SPEAKER_00]: thickness tear in a rotator cuff muscle and be asymptomatic meaning they have no symptom or pain

[00:07:54] [SPEAKER_00]: and so this is what we would call more just like a progressive degenerative tear of that muscle

[00:08:01] [SPEAKER_00]: in a way that the body just compensates for and says okay that's happening we can still do everything

[00:08:07] [SPEAKER_02]: we need to do i know i think it's pretty cool to be able to see that like we you know study

[00:08:13] [SPEAKER_02]: is taking a group of people and imaging their shoulders and about 20 percent are gonna have

[00:08:19] [SPEAKER_02]: rotator cuff tears and have no idea because they don't have any pain and up to two-thirds

[00:08:25] [SPEAKER_02]: of rotator cuff injuries can be completely asymptomatic and i think that's really hopefully

[00:08:30] [SPEAKER_02]: encouraging to hear right like we are saying this because you might have pain and be like but

[00:08:37] [SPEAKER_02]: i'm not part of that group but that's okay because it means that you can be and i think that

[00:08:41] [SPEAKER_02]: is the hopeful thing here right like we could do conservative treatment and you could have healing

[00:08:48] [SPEAKER_02]: of the rotator cuff but you could have also just a reduction in symptoms and back to function and

[00:08:55] [SPEAKER_02]: i think that's what's most important here is that you don't have to have the surgery unless it's

[00:09:01] [SPEAKER_02]: you know you've tried the conservative treatment and it's not working and i think what's also cool

[00:09:06] [SPEAKER_02]: is that there is recently a study at moon and looking at the shoulder group found that the duration

[00:09:11] [SPEAKER_02]: of symptoms so how long you've had shoulder symptoms does not correlate to the severity of

[00:09:18] [SPEAKER_02]: the rotator cuff disease or tear size and i think that's super important to note as well

[00:09:24] [SPEAKER_02]: because it doesn't necessarily mean that how long you've had the shoulder pain correlates to how

[00:09:30] [SPEAKER_00]: bad the tear is and this we find common in a lot of these imaging studies that we see that

[00:09:36] [SPEAKER_00]: what the image looks like the amount of tissue damage does not directly correlate to pain level

[00:09:42] [SPEAKER_00]: because as we know pain is super complex and there's so much more that you know comes into play

[00:09:49] [SPEAKER_00]: when we're talking about the pain experience or the perception of pain there's varying studies

[00:09:53] [SPEAKER_00]: that show how effective conservative treatment is again this depends on a lot of things

[00:09:59] [SPEAKER_00]: location of the tears the variety of the tear level of pain level of disability and function

[00:10:04] [SPEAKER_00]: they did list out factors associated with poor outcomes of conservative treatment

[00:10:12] [SPEAKER_00]: abduction and external rotation strength so abduction is arm coming straight out to the side

[00:10:18] [SPEAKER_00]: external rotation is

[00:10:20] [SPEAKER_00]: arm going away from the body or kind of like if you make a goal post you're putting your

[00:10:25] [SPEAKER_00]: shoulder and the external rotation strength of less than three which essentially means like you

[00:10:30] [SPEAKER_00]: struggle to lift the arm against gravity through full range of motion muscular atrophy so if you're

[00:10:37] [SPEAKER_00]: already seeing you know that rotator cuff muscle you know reduced in size superior migration of the

[00:10:44] [SPEAKER_00]: humoral head which tells us that the rotator cuff muscles are really struggling to keep that

[00:10:50] [SPEAKER_00]: humoral head centered like we said is one of their primary functions decreased glenohumeral passive

[00:10:57] [SPEAKER_00]: range of motion which essentially means that therapists bringing your arm through range of

[00:11:02] [SPEAKER_00]: motion and they notice you have significant decreased range of motion arthritis of the shoulder

[00:11:08] [SPEAKER_00]: active forward flexion of less than 50 degrees which is like barely being able to barely

[00:11:13] [SPEAKER_00]: being able to lift your arm at all anterior cuff tears so tearing one of the anterior muscles

[00:11:20] [SPEAKER_00]: subscapularis tears which is the rotator cuff muscle that does internal rotation and

[00:11:26] [SPEAKER_00]: lack of teres minor hypertrophy so if you have a small atrophy it's just not atrophy of the

[00:11:32] [SPEAKER_00]: teres minor so again those were a lot a lot of that was pretty clinical but those are some of

[00:11:38] [SPEAKER_00]: the if you're seeing these symptoms or if a therapist is seeing these symptoms they should

[00:11:42] [SPEAKER_00]: be saying like hey we can try we can try conservative some of the things i'm seeing might make me think

[00:11:49] [SPEAKER_00]: you're a surgical candidate but as we'll talk about later the mindset that you have is also very

[00:11:55] [SPEAKER_02]: important hugely important i think that's one of the biggest things is patient expectations

[00:12:00] [SPEAKER_02]: and we talk about this a lot across treatments because if you believe a treatment is going to

[00:12:05] [SPEAKER_02]: work if you go in you maybe you heard from a friend or a family member this therapist is the

[00:12:09] [SPEAKER_02]: best they're going to get you better you're going to go in with more belief that this is the

[00:12:14] [SPEAKER_02]: therapist that's going to give you the exercises to help you heal right but if you go in and you've

[00:12:19] [SPEAKER_02]: talked to someone who had surgery and they're like physical therapy didn't work and this doesn't

[00:12:23] [SPEAKER_02]: help and you know good luck on trying it you're going to go in with lower expectations

[00:12:28] [SPEAKER_02]: that this is actually going to help you and you might end up going more toward the surgical

[00:12:33] [SPEAKER_02]: route just because of the belief you had walking in to that clinic so i think that's so

[00:12:39] [SPEAKER_02]: important to note that's not just what we're saying that's literally from the studies

[00:12:43] [SPEAKER_02]: and so no matter what you do if you're gonna if you're gonna say okay i really would love to

[00:12:48] [SPEAKER_02]: avoid surgery believe that the treatment is going to help and if you do not believe your therapist

[00:12:55] [SPEAKER_02]: maybe you're asking more questions you're asking the why and they're just not able to

[00:13:00] [SPEAKER_02]: really give you confidence in that you can see another physical therapist get another therapist

[00:13:04] [SPEAKER_02]: there's not just one and we talk about that a lot but i think what's cool you know is to see that

[00:13:09] [SPEAKER_02]: non-operative treatment in some of these massive rotator cuff tears was reported as successful

[00:13:18] [SPEAKER_02]: in a range from 32 to 100 percent of cases so we can look at this as being so positive that

[00:13:26] [SPEAKER_02]: you know you could have a huge tear in your rotator cuff and still have 100 success of course

[00:13:34] [SPEAKER_02]: this there's many factors that play into this and that's not going to be everyone but taking

[00:13:38] [SPEAKER_02]: that conservative route first i think is really encouraging yeah i don't i really don't think we

[00:13:43] [SPEAKER_00]: can overstate the power of our expectations and our belief that we can make change like

[00:13:48] [SPEAKER_00]: the ability that our brain and body have to work together in order to make change in

[00:13:53] [SPEAKER_00]: our pain levels which then can result in improvement and function is huge that was further pointed out

[00:13:59] [SPEAKER_00]: by studies showing where they would take emotional and mental you know scores at the beginning of

[00:14:05] [SPEAKER_00]: treatment lower emotional mental health scores were associated with lower physical function and

[00:14:11] [SPEAKER_00]: higher pain and disability at initial initial evaluation and then furthermore the patient

[00:14:17] [SPEAKER_00]: expectations as jen said were also so associated with end outcomes you know so lower patient

[00:14:25] [SPEAKER_00]: expectation versus higher patient expectation equaled lower higher outcome so just further showing

[00:14:31] [SPEAKER_00]: that if you're going to commit to the conservative route commit commit full and mind body spirit

[00:14:38] [SPEAKER_00]: that yes i trust that i can make a difference and it will likely have some sway on your

[00:14:45] [SPEAKER_02]: overall outcomes or progress exactly now let's talk about what exercise is i think that's what

[00:14:49] [SPEAKER_02]: everyone wants to do what exercise should i do so i mean in general we're going to be looking at trying

[00:14:55] [SPEAKER_02]: to restore range of motion and also progressively trying to strengthen around those muscles and

[00:15:01] [SPEAKER_02]: so we might start really easy with just um we do some exercises along a wall something you

[00:15:07] [SPEAKER_02]: can do at home where it's just like isometric holds we're just trying to put pressure forward

[00:15:12] [SPEAKER_02]: trying to put pressure back put pressure out to the side you know getting all the the rotator cuff

[00:15:17] [SPEAKER_02]: muscles kind of starting to fire in work in a really controlled manner because your arm is right by your

[00:15:24] [SPEAKER_02]: side you're not having to move it anywhere that can help reduce pain that can help you know just

[00:15:28] [SPEAKER_02]: to start to build that confidence within the shoulder then we do want to get back to like okay can i

[00:15:34] [SPEAKER_02]: start to improve my range of motion going forward my range of motion going out to the side um and

[00:15:40] [SPEAKER_02]: so we'll use more range of motion mobility type exercises um along with some strengthening you

[00:15:46] [SPEAKER_02]: know we're going to do some strengthening and this is where you're going to traditionally see

[00:15:50] [SPEAKER_02]: just strengthening in internal and external rotation you know out to your side starting

[00:15:54] [SPEAKER_02]: to get a little bit higher starting to get a little bit higher and maybe doing some forward

[00:15:58] [SPEAKER_02]: inside raises but this is where we also are going to say and there's more that's what

[00:16:05] [SPEAKER_00]: especially in early treatment you'll generally see people focusing okay directly on the shoulder

[00:16:09] [SPEAKER_00]: yes like you said we're reducing the the swelling or the pain in the area but then also restoring

[00:16:15] [SPEAKER_00]: that range of motion and getting those muscles activating but that's where you know Jen and I

[00:16:19] [SPEAKER_00]: are always like okay and then what what contributed to that initial injury in the first place

[00:16:26] [SPEAKER_00]: what other limitations do we have with the joints around the shoulder that may have resulted in us

[00:16:31] [SPEAKER_00]: putting too much of a strain or pressure on those rotator cuff muscles and that's where

[00:16:37] [SPEAKER_00]: a physical therapist doing an assessment can say like oh well we're having impingement because of

[00:16:42] [SPEAKER_00]: shoulder blade movement or we're noticing you don't have good range of motion in your upper back

[00:16:48] [SPEAKER_00]: in rotation and in extension so uh I mean just sit forward real quick like everyone like kind of

[00:16:54] [SPEAKER_00]: yeah if you slouch in your chair and then lift your arm and then try and lift your arm it probably

[00:17:00] [SPEAKER_02]: doesn't go very high or maybe you get like some of that pinching that you might already

[00:17:04] [SPEAKER_02]: feel in that shoulder and then sit up nice and tall and kind of open up that upper back

[00:17:09] [SPEAKER_02]: and then try to reach overhead oh all of a sudden magic mobility it just improved just from moving

[00:17:17] [SPEAKER_00]: your spine yeah and so positioning in general and just education on how you were positioning

[00:17:23] [SPEAKER_00]: yourself when you go to do an overhead exercise or when you go to reach into a high

[00:17:27] [SPEAKER_00]: cupboard to make it more functional so things that we like to focus on our thoracic mobility

[00:17:32] [SPEAKER_00]: it's huge for getting the arm overhead so important to avoid putting ourselves in potential

[00:17:37] [SPEAKER_00]: impingement ranges of motion ranges of motion that we need to overwork the shoulder to try and get the

[00:17:44] [SPEAKER_00]: same mobility as if we just extend through the upper back so upper back extension doing things like

[00:17:50] [SPEAKER_00]: cat cows cat cows that are more focused on the thoracic spine and then upper back rotation

[00:17:56] [SPEAKER_00]: if we improve rotation through the upper back we're by proxy going to also help improve our

[00:18:01] [SPEAKER_00]: extension as well and our body just loves to rotate and when we reach overhead with one arm

[00:18:06] [SPEAKER_00]: we naturally rotate through our thoracic spine so doing things like an open book exercise or other

[00:18:12] [SPEAKER_00]: thread the needle type exercises that are going to help with your upper back rotation and this

[00:18:17] [SPEAKER_02]: is where okay what else could be restricting along that area um your pecs right we live in

[00:18:24] [SPEAKER_02]: such a forward dominated world we're on our phones run our computers our arms are

[00:18:29] [SPEAKER_02]: forward so can we do exercises to help relax the tension along that chest and then starting to

[00:18:37] [SPEAKER_02]: get that chest more mobile in its full range of motion so not only do I love wall peck stretches

[00:18:44] [SPEAKER_02]: I think that feels so good to do throughout the day and to help to relax that muscle and gain

[00:18:48] [SPEAKER_02]: that range of motion but also when you're doing your your pec exercises like can I go into a full

[00:18:56] [SPEAKER_02]: range of motion push up you know getting my chest all the way to the floor or when I'm doing my my

[00:19:02] [SPEAKER_02]: chest press can I make sure my arms are going all the way back on that bench so I'm opening up my

[00:19:07] [SPEAKER_02]: chest and I'm getting that full range of motion under load we don't understand how much strengthening

[00:19:12] [SPEAKER_02]: in that full range plays a role in improving mobility I think that's really important because

[00:19:18] [SPEAKER_02]: our pecs can often you know take over control of what's happening same with our upper traps

[00:19:23] [SPEAKER_02]: that a lot of times people feel like they get that upper trap you know just kind of taking over

[00:19:27] [SPEAKER_02]: and movement because we haven't retrained how that serratus anterior that punching muscle

[00:19:32] [SPEAKER_02]: is really working with that shoulder blade so this is like so much of what we do in the

[00:19:36] [SPEAKER_02]: shoulder plan is really reworking that entire thoracic pec upper traps serratus area around

[00:19:44] [SPEAKER_00]: the body when you mentioned briefly they're training the serratus which we call our punching

[00:19:48] [SPEAKER_00]: muscle and that it's so important for movement of our shoulder blade which movement of our

[00:19:53] [SPEAKER_00]: shoulder blade is vital to getting full range overhead so there are things where you can do

[00:19:59] [SPEAKER_00]: like on your hands and knees doing what we call just put the plus of the push up plus where

[00:20:05] [SPEAKER_00]: hands are in the ground and you just essentially push your hands and fingertips down into the

[00:20:10] [SPEAKER_00]: ground to get those shoulder blades to glide forward and as you do that more and more

[00:20:14] [SPEAKER_00]: you'll kind of train that pattern of okay when I reach overhead now that serratus anterior

[00:20:20] [SPEAKER_00]: is going to kick on and help glide that shoulder blade and that can be super beneficial to prevent

[00:20:25] [SPEAKER_00]: those impingement type positions of course there's a ton more finding good core coordination

[00:20:33] [SPEAKER_00]: finding good expansion through our ribs our breath patterns can be super important so

[00:20:38] [SPEAKER_00]: that we're not breathing with all of our accessory neck muscles and upper chest muscles

[00:20:43] [SPEAKER_00]: that can cause more restriction which then might cause us to compensate in how we use our

[00:20:48] [SPEAKER_00]: rotator cuff so of course there's always more Jen mentioned the shoulder plan in gen health

[00:20:55] [SPEAKER_00]: great place to start it's a 30 day plan that takes you through a lot of these different types of

[00:20:59] [SPEAKER_00]: exercises that don't focus just on the shoulder but focus fully on the complex from shoulder blade

[00:21:05] [SPEAKER_00]: rib cage core chest upper back it hits it all and we briefly mentioned posture I always talk

[00:21:12] [SPEAKER_00]: about my 30 for 30 rule or 30 every 30 rule if you're working or if you're going to be doing

[00:21:17] [SPEAKER_00]: something in one position for more than 30 minutes set a timer especially if you're going to be working

[00:21:23] [SPEAKER_00]: for four hours six hours eight hours set a timer that goes off every half an hour it can be silent

[00:21:29] [SPEAKER_00]: so once your phone starts buzzing you get up and do one of the things we just talked about extend

[00:21:34] [SPEAKER_00]: rotate through your upper back stretch your chest at the wall you know just lift your arms overhead

[00:21:40] [SPEAKER_00]: and move in a position that you weren't just moving in and get back to work and it doesn't

[00:21:44] [SPEAKER_00]: have to take more than 30 seconds but if you do that every 30 minutes we're doing it 10 to 12 to

[00:21:50] [SPEAKER_00]: 20 times a day and that can be so beneficial in the way it starts to train our nervous system

[00:21:56] [SPEAKER_00]: to feel something different and to not feel like it is always tightening down into this one

[00:22:01] [SPEAKER_00]: position that we're holding thanks for tuning in for another PT pearl hopefully you learned

[00:22:07] [SPEAKER_00]: something or if you know someone out there with shoulder pain or rotator cuff issues please

[00:22:11] [SPEAKER_00]: pass this along also consider leaving a rate and review on your favorite podcasting platform

[00:22:15] [SPEAKER_00]: remember we have that free trial link down in the show notes it's just gen.health backslash

[00:22:21] [SPEAKER_00]: free trial so you can check out the shoulder plan or you can come and join our community we're doing

[00:22:26] [SPEAKER_00]: a full body mobility challenge there's a full 30 day full body mobility plan on gen health

[00:22:32] [SPEAKER_00]: we're giving five dollars off your first month right now so if you use code optimal at checkout

[00:22:37] [SPEAKER_00]: you'll get your first 30 days for just 20 dollars so you can come do this full month challenge with us

[00:22:42] [SPEAKER_00]: for only 20 bucks come join us start moving feel the difference in your body and we'll see you next

[00:22:48] [SPEAKER_00]: time on the optimal body podcast