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View Full Version : Need a shoulder rehab program - advise, please!!



Adam LaClair
10-15-2003, 03:39 PM
I've hurt my shoulder and need a program to rehab it, and I hope very much to avoid surgery! Any advice will be GREATLY appreciated.

INJURY BACKGROUND:
Last July, I was chasing (playfully) a small child relative. She went around a teeter-totter at a playground, but I decided to hurdle the 18 inch high construction instead. As I landed on the crushed rock surface, my left foot slipped, my left knee locked hard, and I went sprawling head first to the ground. I purposefully did not try to brace my fall with my hands, as I was 3 months into recovering from a ligament reconstruction surgery on my left elbow. Instead I tried to just tuck and roll - but all I managed to actually do was turn and slam my right shoulder HARD into the ground, skidding about 6-8 feet in the process. (I weighed about 230 at the time, and was running at a fairly good pace). At the time, I seemed just a little scraped up. "No big deal, could've been worse" I thought. I was worried more about my left knee than anything, as I have had 3 surgeries on it in the past, and I noticed increased crepitation under the kneecap following this event (it has subsided now, however - my knee if fine.)

Anyway, a few days later I was teaching a grappling (no-gi BJJ) class and had a student set up a right armbar from side-mount on me. As I laid on my left side and he trapped and pinned my right arm, I felt EXCRUCIATING shoulder pain as he rested his weight upon my shoulder - this was the first sign I had of an actual injury to my shoulder. When I went to do my Warrior Wellness routine the following day (I usually do it 2-3 times/week), I found it to be painful at best. Clubbells were not happening - it hurt profoundly just to do fore-arm swings with them. I couldn't see any visible swelling, but tried rest & ice just the same. Didn't seem to help. I've tried using a heating pad, but with seemingly no effect. A good thorough warmup hurts to do, but makes working out or rolling less painful, although the next day I usually feel a tremendous increase in both stiffness and pain in the joint.

MY DOCTOR:
I've seen my orthopedist, and he said it's kinda hard to tell - I definitely have at least a severe strain of the supraspinatus, but he is unsure of whether or not I have a partial tear, as well. An MRI is out of the question (I am unemployed and have no insurance right now, and he didn't seem to be optimistic that an MRI would show much anyway). He suggested home therapy - military-style pushups and stretching exercises - for a few months to see how things go. He said if I can't heal it with proper exercise, then the next step would be arthroscopic exploration to see if I indeed have a tear.

MY STATS:
I'm 33 years old (34 in December), 5'10, presently a bit overweight at 215 pounds (and dropping, my goal is 195). I'm fairly fit and quite muscular, but my joints are definitely the "weak links":
Ulna Collateral ligament reconstruction in both elbows - fully recovered
Left ACL reconstruction - all is good now
2 athroscopic surgeries on the Left knee - doing fine right now
Both shoulders have slight crepitation during full arm circles

MY PRESENT SYMPTOMS:
Rolling my shoulder forward while simultaneously raising my elbow to the rear, bringing my forearm to parallel with the floor causes pain. (Just the motion of driving my shoulder forward alone is quite painful!) Extending my straightened arm from my side to parallel (or higher) causes pain just as I begin to go higher than parallel (laterally), or just as I reach paralled (frontally). I can do flys with 100# on a machine with slight discomfort, but bench pressing 100# is absolute torture!! Pushups are okay somedays, other days I cannot perform one single rep without a high degree of pain. Connecting with a right hook (punch)on a bag is not fun! Consciously dropping my shoulder also is painful. If I lie on my shoulder at all at night, I have a terrible time the next day, it seems. Attempting to reach behind (waist level) and scratch my back with my right hand causes the most intense pain of all.

CURRENT ACTIVITY: At this point, I have temporarily given up the clubbells. I only have a single pair of 15#, and I think this is WAY to heavy for rehab. Perhaps when I can afford to get a set of the 5#ers I can give them a try. I'm doing Warrior Wellness almost daily for the last few weeks, but again - some days are better than others. I might have a few days that it seems to help, but then I'll have one day that it hurts so bad just to do 5 or 6 arm circles that I'm not sure if I'm doing any good. I'm still grappling 2-3 days a week, but trying to limit myself to mostly low-moderate intensity drills. I did compete last month, though. Funny thing - it felt BETTER the day after the tournament! I was the smallest guy in all my matches (Superheavyweight), and placed in all 3 divisions I entered (first place in men's blue belt!) I expected the competition to aggravate it, but it didn't hurt hardly at all afterward! However, rolling hard with my own (smaller) students seems to aggravate it quite a bit.

MY EQUIPMENT:
I have a dedicated gym in my house. I have a power rack (barbell work) with attached overhead and low pulleys for back work and an attached pec-fly deck, a leg press machine, a "TOTAL GYM," a Concept II rowing machine, dumbbells, a pair of 15# clubbells, a swiss ball, and a jumprope! :roll:

QUESTIONS:
1.) I feel like I should be doing the circles slowly, really maximizing the range of motion with each one - or am I pushing the joint too hard? Should I be more "gentle," with the circles, or really seeking the "stretch?"
2.) How often should I be doing them? Daily, like I am? Or is this TOO much, and I should go back to just a few times a week?
3.) I read the other post on rotator cuff rehab (with the CST article re-posted), already. Without knowing if I have a tear or not, should I try that program, or do you have another recommedation to try first/alternately?
4.) I want to attend the CST cert. seminar - but from the reviews I've read, I'm having serious concerns as to my ability to make it through the weekend until this shoulder is much more on the mend. I had signed up for the Beta session, but had to back out (last minute schedule conflict, wish I had've attended!!). I'm not attending the Gamma session because I don't feel I'm ready. Your thoughts?

I'm tired of injuries - I just want to be able to train NORMALLY again!!

Frustrated,
Adam LaClair

Doug Szolek
10-15-2003, 06:47 PM
I know others will chime in with more detailed suggestions (my speciality is taking the "healthy" bodies beyond rather than rehabilitating the broken ones, though I'm studying to balance this out) but here are a few that seem like common sense to me.

Stop grappling and stop resistance training (with your arms).

If you've got such a serious precondition, then I can't think of any reason to justify forcing training when the issue has not been healed yet.

I know it sucks to take time off but it sounds like your setting yourself up for a permanently debilitating condition.

Once you come to terms with sitting the sidelines for a few months. Getting to work (softly) on Warrior Wellness may be the way to go. By softly I mean, if it hurts to move the injured shoulder through the full range of motion, then don't. Move it until you feel that discomfort is about to turn to pain and then short cut the motion around the pain so that your are working the around the injury. Continue like this staying in a relatively low rep range with each of the six planes of the shoulder and you should gradually notice the area where discomfort turns to pain dimish in size (we're talking days to weeks here so be patient). As it dimishes in size continue to work just up to and then around it, until it eventually disappears.

This is the method that I used to rehab my broken ankle years ago and it has worked for others. But don't let it substitute the advice of a trained professional. All injuries are different, so you may need to customize this to your specific problem.

The most important thing here, is to stop training though. When you train with an injury, you are grooving inefficient form because whether you feel it or not, your body is working around that injury. Any extended amount of this simply sets you up for more injuries down the road because your strength/technical gains, have been built out of balance. so Please, give yourself time to heal. Play the role of a less hands on coach, suck up your ego, and get healthy so that you can play the games you love the rest of you life and not be forced into retirement from injury.

The only reason that people have to retire, is from not taking time off to heal when they need it. Your shoulder can heal, probably without surgery (but I'm not a doctor, I'm an optimist so don't bank on that :wink: ) but not if you don't let it, and then work to help it.

I'm here to help, let me know how it goes,

rbibbs
10-16-2003, 10:44 PM
Adam, follow Coach Szolek's advice, and your orthopedist's, I can't improve upon those. I can give you an optimistic alternative diagnosis.

You may not have torn anything at all. Shoulder compression injuries compress everything from the humerus, clavicle, the shock can misalign the neck, and any of these actions can pinch nerves. Complex and interdependent as the shoulder is, one muscle not getting its nerve messages or not sending back proprioception can mimic a muscle tear, as far as what it "feels like" to the victim. I've had several that sound very similar to what you describe, and they were all nerve impairments, nothing wrong with the joint structure at all.

Two months is not a "long time" for a nerve injury to recover. (I'm assuming July 03.) It may bother you into next year, I've had them last 6 months, from less-severe strains than falling while running. Do your shoulder WW as Doug describes, as your ROM permits, and also the neck, that whole assembly works together. I'm thinking you're going to get a new year's present. One day it will just start working again. Keep moving it but don't "force" it into the ROM that makes it hurt intensely, and do NOT load it until it's working right again. A muscle not working from nerve impairment CAN tear adjacent ones if you keep stressing the joint and the operative muscles tense to protect the overall integrity.

Rick

bob_stra
10-18-2003, 10:12 AM
Note: The following should not be taken in place of professional diagnosis / second opinion. Think of it as an educated guess. Any and all actions you take are your own. (yeah I know...but my home country just won the dubious award of bring the most litigious place on Earth. Even ahead of California. (ponders if California is technically *on* earth... :)

Off the top of my head, here are some thoughts -

Painful arc present.

Possibly Rotator cuff injury + infraspinatus attachment to humerus, going by injury description. Rib compression?

Was it a kimura type armbar? If so, rotator cuff involvement highlighted.

Injury = 18 months old (last July? as in 2002?). If so, chronic stage. Area weakened. Proprioception reduced. Scar tissue. Type in "chronic muscloskeletal injury" into google and see what advice you get. Here's the first few I found

http://tinyurl.com/reux
http://www.orthop.washington.edu/shoulder_elbow/stiffness
http://www.thestretchinghandbook.com/archives/rotator-cuff-injury.htm
http://www.ortho-u.net/orthoo/4300.htm

Cycle of re injury

MRI out of the question? Ultrasound might be useful alternative?

"Pushing the joint too hard". Technically, the shoulder doesn't have colateral ligaments, so the rotator cuff muscles plays a big role. A better question might be - are you pushing the SITS muscles too hard?

Recommendations - Investigate some soft tissue treatment to the area. Massage therapy at college clinics is wonderfully cheap ($10-15 / hour session). Ask them to focus on your shoulder.

Investigate other alternatives. Personally when I get stumped I've had good results referring folks with frozen shoulder for Feldenkrais, Trager and acupuncture. Take your pick - I favor the first two myself ;-) (neither of which, BTW, are medical solutions to the problem). You might like to investigate the following?

http://www.nas.com/~richf/low25.htm
http://www.nas.com/~richf/low9.htm


The following book is a useful way to educate yourself as to what might be happening and what to do abt it -

http://tinyurl.com/revg

There are some excerpts there, so you can decide if its too highbrow (ps: ignore the reviewers. Its really quite a simple, if fascinating, read)

RE: Your questions

QUESTIONS: 1.) Small, slow circles. Just trust me on this, or you'll get a 1000 word post on the effects of force on collagen remodelling ;-)

2.) How often to do them? Twice a day seems like a good number to pull out of my ass ;-)

3.) I haven't seen the CST article you mention, so I can't comment. Find out what's happening first before you decide on a rehab plan. US is a fairly cheap imaging alternative that might be useful in your case.
(4) See above.

In the end, I think you might want to visit a competent musculoskeletal physical therapist. Believe it or not, it gets pretty complicated in there ;-)

Scott Sonnon
10-18-2003, 10:24 AM
Solid replies everyone. Bob, you've been investing significant time in helping people at CST Forums. Good work.

bob_stra
10-18-2003, 10:59 AM
Solid replies everyone. Bob, you've been investing significant time in helping people at CST Forums. Good work.

Glad to offer what limited help I can.

Kind of my way of saying an extra thanks for filming GTB and IOUF ;-)

Adam LaClair
10-18-2003, 07:13 PM
Thank you all for your time and consideration!!


Stop grappling and stop resistance training (with your arms).

Haven't done resistant training at all in quite a while (other than to just *see* what kind of limitations I had in strength & ROM, and the pushups that the Doc suggested. As far as stopping grappling, OUCH!! That one hurts, but you are ABSOLUTELY CORRECT - it isn't something I want to do, but it IS something I need to do............. so DONE! :(


I know it sucks to take time off but it sounds like your setting yourself up for a permanently debilitating condition.


The only reason that people have to retire, is from not taking time off to heal when they need it. Your shoulder can heal ........ but not if you don't let it, and then work to help it.
Again, I reluctantly have to agree.



I'm here to help, let me know how it goes
Thank you, I sincerely appreciate that, Coach!!

Adam LaClair
10-18-2003, 07:18 PM
Rick,

Your assessment sounds encouraging, logical, and right on the money with what I have learned over the last few days about the shoulder joint and how mine "feels."


I'm thinking you're going to get a new year's present.
Man, I like the sounds of that!! 8)

Solid sounding advice on the WW moves by both Coach Szolek and yourself. Thanks!!

Adam LaClair
10-18-2003, 07:26 PM
Bob,


Was it a kimura type armbar? If so, rotator cuff involvement highlighted.
Nope, just a standard straight arm bar from side control. The pain happened (happens) when my shoulder moves forward and inward. For example, I can replicate the pain by hugging my right elbow directly towards my left shoulder. Feels like something is EXTREMELY tight and does not like the added stress of forced stretching.


Injury = 18 months old (last July? as in 2002?).
No, July 2003.


Recommendations - Investigate some soft tissue treatment to the area. Massage therapy at college clinics is wonderfully cheap ($10-15 / hour session). Ask them to focus on your shoulder.
Already thought of this and have had two massages. Has actually helped quite a bit, and I was told by both people that I have a ridiculous amount of tension in that shoulder. I will pursue this method of treatment further, as well as abstaining from resistance moves (grappling :cry: ) and doing the WW as you all have described (slow, gentle, and a couple of times per day).

I'll check out the links you posted, as well. Thanks!!

Adam LaClair
10-18-2003, 07:29 PM
Coach Sonnon,

I'm a "Noob" to this forum, but it has already been one of the more helpful and "constructive-use" places I've been to. Thank you for providing us with this venue of communication! :D

I intend to see you at a CST course before the end of 2004!! :!:

Adam

Scott Sonnon
10-18-2003, 07:41 PM
Adam, I'm proud that you're a member of the Tribe! Recovery quickly and fully, amigo.

Adam LaClair
10-20-2003, 11:24 PM
Thank you, Scott. Glad to be here!!

:D

Adam

cobb
10-21-2003, 07:36 PM
Adam:

My apologies for taking so long to get to this... I've been on the road almost constantly for the last month and a half... Not a good excuse, but a real one.

I read through all of the posts here - they are all excellent advice and I will not hesitate to reiterate it all - including the standard Internet diagnosis disclaimer to see your doctor. However, let me also add a couple of ideas.

If you have indeed "compressed" the shoulder and all of it's assorted joints, muscles, tendons, and ligaments, you may want to sneak in the backdoor with your rehabilitation. The best and most likely immediate bets are that you need to emphasize not just shoulder mobility from Warrior Wellness, but also neck and thoracic circles. Do them slowly and look for "catches" and areas of incoordination in all ranges of motion.

For the shoulder itself, in addition to the basic 6 DOF arm circles, you also need to implement the shoulder "cam-shafts" in a non-painful range ASAP. You may indeed be suffering from a distinct loss of proprioceptive input that this exercise will greatly restore.

Finally, you need to mobilize the heck out of your opposite side foot, ankle and knee... While you injured the shoulder in the fall, the delay in healing may also be a result of altered lower body/upper body synchronicity relating back to your last knee surgery.

Good luck with this. Please keep us informed.

Dr. C
Z-Health Performance Solutions

Doug Szolek
10-21-2003, 10:28 PM
Dr. C, your insight into the human anatomy borders on scary sometimes :wink:

Adam LaClair
10-23-2003, 10:44 AM
Thanks, Eric.


The best and most likely immediate bets are that you need to emphasize not just shoulder mobility from Warrior Wellness™, but also neck and thoracic circles.

For the shoulder itself, in addition to the basic 6 DOF arm circles, you also need to implement the shoulder "cam-shafts" in a non-painful range ASAP.
I am not familiar with these movements (at least not off the top of my head). Can someone provide a description, and also a reference to a video or something that shows them?


Finally, you need to mobilize the heck out of your opposite side foot, ankle and knee...
What is the best approach to achieve this? Will Warrior Wellness be sufficient?

Thanks!!

Adam

Scott Sonnon
10-23-2003, 10:48 AM
Adam,
Cam Shafts are in Warrior Wellness, and, yes, the Warrior Wellness courses are sufficient. They're all you'll ever need.

Adam LaClair
10-23-2003, 09:16 PM
Thanks Scott.

I'm assuming the cam shafts aren't in the 1st tape - I'll check out the other two (I have them, just haven't been "ready" for them yet).

Thanks again,

Adam