Injuries and RehabTell us where it hurts! Do a quick search before asking about your shoulder injury to make sure your question hasn't already been answered (about 50 times), and read the sticky post first.
I have been doing pretty well with my recovery thus far. My back is better, my neck is ten times better, my forearm seems to have recovered really well, my knee is about 60% better, but my DAMN SHOULDERS!!! ARGH! I worked out today and the damn thing felt still feels like it was ripped from my body, used as a blugeon against some spike covered animal, then sewn back on using a broken bottle for a needle and a garden hose for thread. Needless to say, my entire right arm is pretty much out of commission. I have taken about 4 alleves since then, and I have iced my shoulder twice for about 20 each time. Anything else, oh God of broken people?
JP,
I still don't have enought history on you. You've mentioned in the past that you've had several surgeries but I don't know what for? Also a specific symptom pattern will help. What specific movements, exercises, positions, etc. are painful? Are there any relieving positions?
Have you followed previous recommendations from the other post? Is there anyone handy that can do some specific muscle testing on you?
When was the last time you were x-rayed for arthritic changes or MRIed for any soft-tissue issues?
This is the one shoulder that I have only had ONE surgery on. The other one has had three. It was done through a scope, and it was a pretty standard "decompression". They resected a portion of my acromian. I guess I have a natural genetic proclivity for shoulder injury because of the "hooking" shape of my acromians. I had severe shoulder impingement, and the ortho said that my bursa sac was nothing but a wad of scar tissue, so he took it out too so I could grow a new one.
Right now it feels like the origin of my biceps and some spot down on my scapula are the major points of pain. I experience very VERY temporary relief when I pop my shoulder. Now I am trying NOT to pop it, and keep it on ice as often as I can tolerate.
It hurts to do incline bench press. Doesn't bother me too bad to press over head, but if I do I never go heavy at all.
Man would I like to get my hands on your shoulder. That doesn't quite sound right does it??
Sounds like you're dealing with a massive instability problem (the "pop" is a dead give-away...it also indicates subscapularis dysfunction). This is especially true if they took your coraco-acromial ligament with your acromioplasty. They frequently do take it with the "hook" of your acromion (Type 2 shoulder). In the opinion of many orthos it doesn't do anything but increase impingement (Well then what the hell is it doing there!!!!).
If you're symptoms are rather broad, you're going to have a great deal of "extra gook" building up in your delts and cuff tissue. It's simply in response to the added stress of stabilizing the glenohumeral joint. The added strain on the "new" non-extensible soft tissues causes a lot of pain. You'll also overload the AC joint in the process.
I don't think any extra stretching is going to do you a lot of good. I do think some really aggressive soft tissue work will.
You're also going to be very weak in some common positions of the shoulder during some exercises which will still promote some impingement even if you had an acromioplasty.
You must radically change your upper body workouts.
First, stop beating your self up.
No overhead pressing or exercises above shoulder level. These require too much stability that you don't have yet. You're probably destroying your joint in attmpting to do so.
Second, A lot of focus on your cuff musculature and mid/lower traps. Find out what positions are weak. If you don't have a therapist handy let me know. I can explain some common positions for you to test.
Third, Get some aggressive (the hurtin' kind) soft tissue work done especially the subscapularis, lats, pecs, and anterior delts. If you can find someone that uses tools a la ASTM or rolfing, great!
I also keep thinking there's going to be a link between your shoulder pain and neck pain, but it's hard to tell exactly what via email.
Did you get the simple rehab workout I posted in your other shoulder pain post?
You can also start doing some isometrics. Shoulder flexion, horizontal adduction, horizontal abduction (avoid end range of motion as it will exacerbate the instability) in the painfree ranges. 4 times a week, 6-15 second holds for 6 reps each position.
Go to my website and check your shoulder ROM using the rotation tests on the self-assessment and let me know the outcome.
Start using a lot of contrast showers to the shoulder to increase blood flow and pay attention to posture. Any rounding of the shoulders or slouching is now a NO-NO.
You stated that JP had a massive instability problem/ subscapularis dysfunction indicated by his shoulder popping. What kind of popping are we talking about here?
A pop any time you fully rotate the shoulder joint? How about a pop during pulling movements?
The popping can occur with just about any movement of the shoulder, but usually occurs when the subscap. fires or is supposed to fire. For instance, in an anterior instability, if you internally rotate and extend the glenohumeral joint, you'll often hear the reduction ("pop") of the GH joint as the subscap fires and repositions the glenoid. Kinda like cracking your knuckles. You can also do the same thing by placing your hand on your hip with fingers pointing downward and isometrically adducting the shoulder. A lot of my patients do this unconsciously to relieve pain.
The subscapularis provides anterior stability for the shoulder during pushing and pulling movements, so it gets used a lot...overused. Over time, it can lose extensibility and contractility and fail to provide sufficient stability. That's when we start to see rotator cuff strains, tears, impingements, bicipital tendonitis, etc. This is so common in weight trained athletes it's not even funny.
Understand that I'm just putting the pieces of the puzzle together based on what I know of JP's shoulder problems and the common dysfunctions I see in clinic with patients with similar history. Diagnosis via forum/email is difficult. I hoping to get to eval him directly in the near future.
Do you have an alternative diagnosis or a problem yourself?
Do you think that it's a concept of the subscap (or the musculo-tendon unit, as opposed to the muscle tissue alone) actually physically changing (i.e. becoming more lax, losing "contractility") or perhaps strength deficits (either weak subscap, or overly strong subscap antagonists) that cause the loss of stability?
I'm not convinced that the subscap really changes all that much. Atrophy, perhaps, strength deficit/imbalance, definitely, but actual tissue/cellular changes, I'm not so sure.
I'm trained to think it to be changes in the tissues themselves (adhesions, scar tissue, etc.), but I think there's a much stronger neural component.
For instance, when I apply ART to a "tight" subscap and external rotation strength improves immediately I don't think it could have anything to do with the tissue itself. Perhaps an alteration on a proprioceptive level or influencing the spindle/GTO mechanisms. Much like when you apply pressure to a tendon of a hypertonic muscle in a head injury patient and the muscle "relaxes" or applying pressure (or vibration or sweeping contact) to the muscle belly and tone increases.
It certainly makes Janda's conjectures about long and weak and short and facilitated muscles seem possible.
Do you have an alternative diagnosis or a problem yourself?
Your diagnosis sounds much better than anything I could come up with. *chuckles* Seriously though, I have a bit of a problem myself.
The past few weeks I started having a small/minor amount a pain exclusive to the anterior deltoid, and the exact anterior stability problem you described when internally rotating; a pop of the GH joint. Coincidently, I have a full ROM in both external and internal rotation.
When the pain first showed up, I assumed I was overtraining my rotators. I took a week off. Then my following program backed off my pushing and pulling movements (as I was doing a truckload of pushups) and removed shoulder presses. This seemed to help nearly instantly.
I then added a number of static shoulder stretches to my normal stretch routine. After doing the extra stretches for nearly a month, I'd have to say my problems seem to have increased. My shoulder feels looser and pops much more often, and the pain seems to have increased. This leads me to another question: Can stretching sometimes be detrimental to recovery of muscles & connective tissue in an already overused joint? I have a few guesses after digging up some info and this experience, but....
Derek,
If your stretches reinforced the instability then, yes, they can make it worse. Doorway stretches, pec stretches, and biceps stretches can certainly add to your anterior instability.
External rotation with the shoulder abducted to 90 degrees will place tension on the anterior capsule of the GH joint. External rotation with the arm at your side will emphasize flexibility of the subscapularis.
Cumulative injuries can worsen on their own by creatiing a pattern of pain, altered/protective function, atrophy/adhesion/facilitation, altered mechanics, pain, altered/protective function, etc. Even if you attempt to halt it, it may take some direct soft-tissue treatment to resolve.
Recheck your internal rotation by putting both arms behind your back simultaneously and reach upward. Is there a difference? If so, your infraspinatus or posterior capsule may be problematic (short, tight, weak, etc.).
My best recommendation I can give you is to spend the next few weeks strengthening your cuff in all planes and work on your stabilizers like lower and mid traps and serratus anterior. Avoid pure abduction unless it is painfree.
First off, I hope I am making sense. If I say something stupid, feel free to verbally embarass me. I gotta learn somehow. [img]smile.gif[/img]
Well, with your simultanious internal rotation test, I have no shoulders to compare to. Interestingly, the problem is occuring in both shoulders nearly equally. The test does seem to temporarily aggravate the delt.
I actually sat down and tested my planes of movement to see which ones caused pain. I was suprised to find pain (or "noise") in nearly all of them, except frontal shoulder adduction. Anywho, didn't expect that.
Do you have any recommendations for my new priority: rotator cuff repair? In your Rebuilding the Foundation post, you've laid out a little plan. Although, I don't know what to make of some of it. I think T-mag had an article with a rotator cuff "strengthening" plan on it too.
Derek, Feeling more and more a newbie the more he learns
My humble apologies, I was thinking you had only one side affected thus the comparative test.
If you're painful in multiple planes, I think it's time to get the shoulders looked at. If you have full flexion and abduction of the shoulders and can control your arm as you lower it, you probably don't have a tear of the cuff. You could however have some sort of other issue like a labrum injury or a whole bunch of "itis" which would create a nice instability/pain and also produce a great deal of popping and cracking noises.
I would be hesitant to recommend a whole lot of exercise until your shoulders calm down or until you get some sort of clearance from an ortho doc. I just don't want you to aggrevate something that could be more serious. You could try some light pure plane external rotation with the arm in neutral or some isometrics below pain threshold and maintain motion in a painfree manner (passively if necessary), but I wouldn't be too aggressive.
Ice, rest, anit-inflammatories, and get 'em checked. Sorry I don't have more to offer at this point.
My treatment options aren't the best over here. Due to the beauracracy of the military medical system, it will be about 2-4 months before I could see anyone. Even if they let me.
I think it is rolling the dice on the doctors out in town (not military docs and specialists, who usually are at least standard and some are good). The Guam local hospital doesn't have JACHO accredation, and hasn't for 12 years, I think. A hospital in the states would be shut down for such a thing, but obviously the standards are much lower out here.
A whole bunch of "itis"? I don't know if I've never heard the abbr. but I assume you mean minor injuries?
Anywho, the pain isn't great in any of the planes. I am mostly experiencing a lot of popping. And the minor delt pain mentioned. I think I am going to try a short upper body rest and see where I am. My previous week off made me feel new again.
I'd hate to make a big deal out of something that might be really minor. Never had any shoulder problems until now, so... Howabout I get a plane ticket, fly the 24 hours to Indianapolis, and get a real evaluation? That would be a great break from this hell of an island. Plus, I'd know I'd be getting great treatment. [img]smile.gif[/img]
Hopefully, next week, I'll be temporarily fixed and can begin the proccess of strengthing the cuff.
"itis" = inflammation...tendonitis (inflammation of the tendon), bursitis (inflammation of the bursae), arthritis (inflammation of the arthur, er, uh, I mean joint)...get it?
Take your rest. When you start upper body again, try focusinng on PNF patterns, lower trap strengthening, and simple cuff exercises. Hold off on any pushing ex. Let me know if you need some direction there, and I'll do my best to find some photos or something for you.
FYI...Anterior shoulder pain is rarely due to the deltoid but rather something beneath it. Lats, pecs, subscapularis (often the culprit), infraspinatus, and biceps tendon all insert in close proximity to one another at the anterior aspect of the humerus. You also have the AC joint and glenoid labrum which influence the same area.
Rest, ice, anti-inflammatories and train what you can while you rest the shoulder. It's good for you [img]smile.gif[/img]
Keep us all posted.
Bill Hartman, HARTMAN Certified
P.S. I'm guessing Guam is warmer than Indy in October? At least it's a short ride to the beach!
Anterior shoulder pain is rarely due to the deltoid but rather something beneath it. Lats, pecs, subscapularis (often the culprit), infraspinatus, and biceps tendon all insert in close proximity to one another at the anterior aspect of the humerus.
Okay Bill, I'll admit I had some deeper shoulder pain. But, it seemed like on top of it the delts were killing me, especially 24-48 hours after push/pull wkouts. I'll try to explain why I was thinking that and maybe you can fix me if my knowledge is broken.
The Subscap, along with the Teres Major, Minor and Infraspinatus rotate the the arm. Subscap/Teres Major (along with Lats & Pec Major) are responsible for Medial or Internal Rotation. The Deltoid is the major abductor of the arm, meaning it moves the arm outward from the body.
So, in a common move such as the bench press the deltoid and the internal rotators(mostly internal rotators) work together to stabilize the shoulder joint. (It would seem like that if you just had a list of origin and insertion points). If the internal rotators are burnt out/overused is the deltoid forced to work harder to keep your shoulder in place? So, could you begin to suffer overuse injuries there? Or do you know your subscap is done when your shoulder falls out of socket?
Thanks for your help Bill.
In other news, the shoulder already feels about 500% better after a week of upper body rest and ice, etc... I am going to post my cuff strengthening plan here, and let you guys tell me where the holes are.
The deltoid wouldn't be considered a stabilizer but rather a prime mover. Any dysfunction in the dynamic stabilizers (the cuff) will alter the position of the humeral head on the glenoid. Then it's easy to wear and tear on the tissues from impingement and overuse due to altered joint mechanics.
The delts themselves are pretty durable but can be overused in typical fashion (too much weight, too frequent training, too high volume). Because if the natural instability of the GH joint (no joint circumducts to the degree of the GH joint), most injuries occur closer to the joint at the cuff and surrounding tissues.
If you shoulder ever falls out of "socket", see a doctor . Instability at rest or after exercise could be caused by pain, fatigue, posture, or something else I can't think of at this point.
Bill, how does this look to you? I am going to start trying to strengthing my rotator cuff and stabilizers. I plan on doing the wkout for a month and reevalutating where I am after that.
Feel free to let me have it, if I missed something important. Thanks.
Day 1 & 4: Upper Body
Warmup
Barbell Complex
Week 1-2: 3x10
Week 3-4: 3x6
Cuban Press
Dumbell Front Lateral Raise
Side Lying Int Rotation
Side Lying Ext Rotation
Remember the statute of fitness limitations as you return to normal and rehab activities. To stay pain-free:
Limited intensity or load
Limited duration (of a movement or set)
Limited volume (of an exercise or session)
Limited density (work to rest ratio)
Limited acceleration/deceleration
Limited power
Limited rate of force development
Limited velocity
Limited range of motion
Limited complexity (i.e., split squat to lunge to multiple angle lunge)
Be cautious with any wide grip or pushing activities (especially the dips due to the shoulder extension and potential anterior instability). You may find them aggrevating. Anything snatch-grip (BB complex) may also bother you.
Well, the dips are actually "chair dips" as I dont have a dip station here at the house, and they are at a reduced amount. [img]smile.gif[/img]
Pull-ups haven't really been a problem so far, and I wanted to find a way to hit the lower traps without your basic horizontal push/pull(T-Bar Row, Bent Over Row) which were giving me the issues. I could always do your basic Barbell Shrug instead, at a 3x10 then 3x6 range. Othe suggestions?
The Barbell complex is just a very basic one with a standard bar, standard shoulder-width grip.
Well, just wanted to update. I've done the workout nearly exactly as listed above (minus dips)for a full week now and my shoulders feel great. They have tightened up considerably, and don't hurt through full ROM movements. They rarely pop anymore.
The workout is harder than it looks, I'll tell ya that. I think by a full month cycle of this, I'll be in great shape for the future. Thanks for all your help Bill, the amount of advice you give to people you don't know for free is astounding.
An update on my shoulder for Bill and other interested readers...
I had an MRI last Wed, and I got the results today. According to the MRI, my joint is technically healthy. I do have a small cyst in my AC joint, but he said that it was inconsequential, and was not causing the specific pain I was complaining about. Good new though, no torn rotators, which is what I was afraid of. The only problem then is that there is no real diagnosis. I just have to keep suffering. I am meeting with a physical therapist next Tuesday, and I am going to have them give me my recovery routine and do it on my own. The doc did give me cortizone injection, and he also said that it was very difficult to push the needle in, meaning that my bursa probably has a bit of scar tissue in it because it was very hard. Right at the moment my shoulder feels great. I looooove cortizone! He had injected my wrist last week, and put me in a splint for 6 weeks. This is for the injury I got racing last July that has not healed yet. Hopefully this will do it.
Sure would be great to have an ART practitioner in the area! I'll bet THAT would really fix this quickly and get me back in the gym!
Thought I'd try to use this shoulder thread for my question. I used to do the pec deck and had shoulder problems. I was told that this can cause shoulder problems, I stopped using it (along with some other things I changed) and I haven't had any shoulder problems for a while.
I have a college age friend who I noticed was going very heavy on the pec deck. I talked to him briefly about my experience with it but I don't think he's inclined to change anything at this point. He's not having shoulder problems currently.
My question is, should the pec deck never be used or is this more an individual thing, i.e., if it hurts, don't do it. I thought there was a fundamental problem with the type of strain this machine puts on your shoulder and, if so, I'd like to pass on the info to this friend. Does anyone have any good info to pass on?
So Bill, should I start doing light external rotator strengthening exercises? What should be my first plan of action (short of getting extensive ART treatments since I don't have that available)?
I'll bet THAT would really fix this quickly and get me back in the gym!
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