Conflicting Advice: Rotator Cuff

[delta]

I've been getting conflicting advice from different "experts" on my rotator cuff problems, so I wanted to throw my story out there and see what the general population thinks. I'm going to throw in all the details in case it matters. I greatly appreciate any advice or comments:

I'm a 28 year-old guy. About a year ago I took about 2 months off lifting, and when I started again I had a pain in my shoulders (mostly right) that I would get from benching and from swimming the crawl. Went to an ortho, got x-rays, diagnosed as impingement. I did physical therapy for a few months, quit lifting, and altered my swim stroke so my pinky was the first finger to hit the water. Physical therapy included:
Exercises
1) external rotations
2) reverse flies
3) pulling down ropes/bands with arms extended in front, pulling my hands down to my sides while squeezing and lowering shoulder blades
4) supraspinatus exercise: raising db's in front with thumbs up, arms at 45 degree angle from my thorax

Stretches:
1) pulling neck to side
2) pulling neck to hip (traps stretch)
3) pecs and anterior shoulder stretch against a corner

After a few months, I was back to lifting and swimming again. Then I hurt my back (an old injury) and quit lifting (including my shoulder exercises) and only was swimming (increased to 5x per week), but still kept my shoulder stretches. After 3 months, went to lift again VERY lightly. I did bench, assisted pull ups, assisted dips, seated rows, leg raises with arms hammocks, and my shoulder rehab exercises. No problem while lifting, but 2 hours later I developed pain in left shoulder when abducting my arm with arm extended. This developed into a constant aching pain in the lateral aspect of my upper arm.

Went back to the ortho and he said it was tendinitis of the rotator cuff. He said I could do anything (swimming, lifting, etc.) as long as it didn't hurt WHILE I did it. He said I should be doing the same rehab exercises.

I happened to speak with another doc (this one a primary care with a sports med fellowship) and he said don't do ANYTHING for 6 weeks except these different rehab exercises: a "pendulum swing," "wall crawl," and external rotations.

It's been 3 weeks since the initial pain, and in the last week I've had very little pain with daily activities. Who should I listen to? I'd love to go for a swim, but I fear that it won't hurt while swimming but the inflammation will set in a few hours later and I'll have to wait ANOTHER six weeks! What is riskier, swimming crawl, or doing some weight lifting? Who has the right idea with which rehab exercises to do and when to start them. Should I be working my supraspinatus when that is the tendon that is inflammed? What should I start first, swimming or lifting. Should I do rehab exercises for a period of time before start one of those activities?

What about this pendulum swing exercise: Some people seem to recommend doing it while leaning over next to a table, but UpToDate says to do it standing because leaning can cause problems:
http://patients.uptodate.com/image.a...ix/pendul1.gif

Thanks for reading the whole thing!

[Bill Hartman]

Without an exam I can't be exact to your needs but here goes.

Swimming the crawl is an internal rotation activity. Repetitive internal rotation will eventually cause impingement, or in other words, swimmer's shoulder. Don't swim. You have not reestablished normal shoulder function and would therefore end up where you started. Your increased frequency was probably the killer.

You also appear to have some laxity or acquired instability that promotes impingement as well. That means on some level the appropriate rehab exercises will be part of your lifestyle.

Unless you are acute and unable to move much at all, pendulum exercises (the pic you posted is not a pendulum exercise that would be recommended for shoulder pain) are a waste of time. Wallcrawling exercises are a great way to repetitively impinge your rotator cuff and bursae unless you have normal strength of your cuff to overcome the laxity/instability and the pull of the deltoid.

Here's your don't list until you are asymptomatic:
vertical pressing
horizontal pressing
abduction (lateral raises in any plane)...what you called supraspinatus exercise)
Dips (never ever do them again)
upright rows (never ever do them again)
Pull-ups/Chin-ups

To do list:
If you can't reach behind your back and touch the opposite shoulder blade stretch the posterior capsule.
External rotation at 0, 45, and 90 degrees of abduction(this is a progression based on symptoms. More abduction as pain decreases)
I's, T's, and Y's (Hughston exercises)
All forms of rowing with emphasis on scapular retraction
Push-up plus
Standing internal rotation with your band
Stretch all internal shoulder rotators (pecs, lats, subscapularis)
Stretch downward scapular rotators (levator scapula, rhomboids)

These represent early rehab exercises.

You would then introduce raises in the scapular plane. First in sidelying and then standing. Then Blackburn's and scapular depression in sitting (like the top few inches of a dip). Then push-ups on the wall and progress downward toward the floor as symptoms allow, Inverted rows, and single leg squats.

Then DB floor presses and cable PNF exercises, board presses, partial DB presses in the scapular plane.

Truth be told you may never be able to do barbell bench presses or overhead presses ever again.

You cannot transition from early rehab ex. to normal strength training. Emphasize high reps like sets of 20-30 through your rehab exercises. Emphasize slow eccentric and controlled concentric.

Google if you don't know the exercises.

Bill

[delta]

Thank you so much for all that advice. I really appreciate it. A couple questions:

When rehab is over, which of the exercises should I expect to keep in my permanent routine?

Is it ok to do some of the rehab exercise without days off for rest?