Shoulder pain revisited

[pjb923]

I posted a while back about some shoulder pain and did not have all the information needed for a decent diagnosis.

I have been avoiding overhead pressing movements, incorporating shoulder mobility movements and better warm-ups into my workouts and continue to do rotator cuff work a few days a week. Once a week a complete the full GPP routine as outlined in Neanderthal No More part IV, and I have been performing daily stretching. Everything seemed to be going great until the other night while doing bent over lateral raises using 25lb db's, when i experienced sudden pain in my right shoulder.

The pain seems to be located in the area of the attachment point of the Infraspinatus or teres minor. Near the head of the humerus. I am able to perform standing side and front lateral raises with no pain at all, and the bent over raises do not cause pain unless I am using weights. As little as 5 lbs is enough.

During the bent over lateral raise, if 0 degrees = arms straight down and 90 degrees = arms straight out to the side, I can get to around 70-75 degrees before it starts to hurt. At that point it almost feels like the joint is moving out of position and causes a sudden pain.

I took a short video of myself performing a bent lateral raise in case it was a form issue. You can see by the expression on my face at the end that it did not feel good.
http://www.pberge.com/jp/MVI_2639.AVI

A day later, any type of internal or external rotation causes some minor pain. Things like reaching across my body to put my seatbelt on.

I am able to do dips, bench press, pull-ups and seated rows all without any problem, and have been diligent in keeping my shoulder blades pinned back in the proper position during all of these movements.

If anyone can think of a different movement, or just another angle that I can take a video or even a picture of, let me know.

I hope this time around I gave all the necessary information.
Thanks in advance for your help.

[John Izzo]

Paul, I had that SAME expression 3 years ago and then went thru surgery 6 months later.

The only movement I can recommend bro, is a visit to your orthopeadist. Request a MRI, possibly with gadalideean dye injection so they can check the labrum.

[Bill Hartman]

If the video is representative of your typical technique, then I'd lean toward an internal impingement (the pain is located where you would reach across you body and scratch the back of you shoulder). You're horizontally abducting and externally rotating beyond the plane of the scapula. The cuff then gets pinched where it crosses the joint. Happens all the time in baseball pitchers and tennis players and anyone with excessive shoulder laxity like bodybuilders and powerlifters.

You most likely need to stretch your external rotators/posterior capsule and the pec minor as well. Follow this with internal rotations at just less than 90 degrees of abduction. Then focus on strengthening the scapular muscles without the excessive horizontal abduction. Lead the movement with the scapula rather than driving the motion with the arm and momentum. Look for exercises like Y's, T's, and I's; Hughston exercises; and prone trap raises.

As your symptoms resolve, add in external rotation strengthening.

Things to avoid:

All pressing motions, dips, and anything behind the head. These all can increase your anterior shoulder laxity and promote your current condition.

No need to panic just yet. If symptoms don't improve or worsen in 2-3 weeks get it checked.

Bill

[pjb923]

Thanks for all the suggestions Bill. I will try out your method and, like you said, if things don't start improving it will be time to get checked out by an Orthopedist as suggested by John.

For now, lots of stretching and no more pressing movements. I'll post any updates if my condition changes.

[Frank.S]

Does your shoulder routine have extrenal/external rotation? I added these in, along with cuban presses and a few other things i found on the internet. these hurt for a while but now my shoulder seems to be much better, and for a few weeks there it sounds almost as bad as yours is.

[pjb923]

I added some cable internal rotations to my routine last night and they felt really good.

For the last few workouts of my current routine I am going to avoid any type of pressing movement. Then I have a rest week coming up, where I will continue my stretching routine and internal rotator work.

Bill, flat bench press has never bothered my shoulder before. If my shoulder starts to feel better after my rest week do you think I should still avoid ALL pressing movements, or just overhead presses and dips? I was under the impression that bench pressing with proper form (elbows tucked, shoulder blades pulled back tight) could actually be helpful.

I'm starting to think about which routine i'm starting next, and need to know how to structure it. Any substitute exercises you can recommend would be great.

Thanks again.

[Bill Hartman]

Originally Posted by pjb923

Bill, flat bench press has never bothered my shoulder before.

Funny. This is the exact phrase that EVERYONE I've ever treated says the first time they get injured.

This implies that what you have been doing is creating a situation that is altering your ability to function normally and without pain. Should it continue, it may result in permanent restrictions to your activities.

Do you think that a rest week can resolve instability of your shoulder?

Do you think that a rest week can reduce your posterior shoulder stiffness?

I only ask because I understand where you're coming from.

I would suggest you address the necessary issues (even get an assessment done on your shoulders) before you attempt to return to your regular activities.

When you do comeback, don't start with bench presses. Push-up variations, limited range presses, cable exercises, etc. to start and then work your way back to greater range of motion exercises and periodic BB pressing if you must.

Bill

[pjb923]

I think it's time for an update since a lot has happened since I posted last.

I went to see an Orthopedist on before I went on vacation. After a series of tests, applying force in different directions, internal and external rotation, some range of motion tests, her diagnosis was rotator cuff tendinitis.

The test that caused me the most discomfort was internal rotation with my elbows at my side, pushing her hands together. Once the force exerted was great enough it started to cause pain. I asked about the possibility of a tear and she said based on her evaluation that it was not likely. There were a few tests that should have caused pain if i had a tear, but didn't give me any problem. She took an x-ray just to rule out any bone irregularities and everything looked normal. The recommended treatment is 4-6 weeks of Physical therapy. She wants to see me again after the therapy and if my symptoms still exist an MRI may be necessary.

My first visit with the Physical Therapist was Monday. It was mostly an evaluation, but she had me do a few cable rotation exercises, did some ultrasound, and ended with heat and electrostimulation for 10 minutes.

My first real visit was today. Physical Therapy Consisted of:
A 6 minute warmup on the Upper body ergometer. 3 minutes forward, 3 minutes backwards.
Prone DB rows, to the waist:20lbs, 3 sets of 10
Prone T’s: 4lbs, 3 sets of 10
Prone I’s (hands go to hip): 10lbs, 2 sets of 10, Third set with 5lbs.
Cable pull to shoulder (cable set at shoulder height), light: 3 sets of 10
IR and ER (elbow at side): light, 2 sets of 10
Theraband IR and ER (elbow at side,faster tempo) 2 sets of 10
Theraband row to the shoulder (both arms together): 2 sets of 10
Inclined Ball pushup (hands on ball elevated on mini tramp): 2 sets of 10
After the exercise portion was done, we did about 10 minutes of Therapeutic Ultrasound. Then ended with 10 minutes of electrostimulation and a cold compress. The whole session lasted just under an hour and I feel that it went really well. I wasn't sure what to expect. I was a little surprised by the volume of work they had me do, but it may be exactly what i need. Maybe my approach was not aggresive enough. I am scheduled for 2 sessions per week for 4 weeks. She also wants me to add internal and external cable rotations to my normal workouts, 3x a week.

Both the orthopedist and the phsical therapist agreed that I should avoid any type of overhead pressing. But they both feel that regular bench press should be ok for me. The physical therapist just said to stay away from very heavy weights while benching. I just started NROL Strength I and made a significant amount of modifications to the routine to take these things into account. NROL calls for wave loaded bench press sets going from 6 reps down to singles. I have eliminated the heavy singles and switched to a 4x6 scheme in order to keep the weight down a little. Obviously all overhead movements were also removed from the routine. Flat bench press now is the only pressing movement in the routine. Anyone who is interested can see all the details in my log.

Bill, thank you again for your advice so far. I see where you are coming from with your post about bench pressing. The last thing I want is for you to think that I don't value your opinion because I added bench pressing back into my routine. I would be interested in hearing how you feel after seeing the ortho's diagnosis, and your thoughts on the treatment so far.

I'm also curious about the use of heat and/or cold during the electrostimulation. My first visit they used heat, this time it was cold. Is there a specific reason for doing this?