Another shoulder rehab question...

[L_J]

I've been having some problems with my shoulder tendons, mainly the supraspinatus for about two years now. I've had a few cortisone shots in that time but recently saw a respected sports physician about it. The cause of the problems was diagnosed to be the forward-alignment of my shoulders which makes the space all the shoulder tendons attach to the bone get cramped and causes inflammation.

The doctor said all movements where the upper arm goes over horizontal are detrimental. And recommended I do different kinds of rowing exercises to fix my shoulder posture. (The next step would be surgically removing some of the bone to create more space, *ouch*) We had some time to chat about different sorts of exercises etc. but I'd be interested in hearing if you guys have any suggestions on (mainly BW?) exercises I could use while rehabbing that shoulder. Unfortunately living in Finland I don't have reasonable access to clubbells so that's sort of out of the question.

Thanks,
Lauri

[Scott Sonnon]

Follow your doctors advice, Lauri.

[bob_stra]

Well Lauri, nothing I say should ever be taken in place of your doctors opinion. So think of this as one guy howling at the moon ;-)

Some questions & comments

>The cause of the problems was diagnosed to be the forward-alignment >of my shoulders

Is there a medical reason as to why your shoulders are forward-alligned? Dowager's hump, Tuberculosis, ALS, Osteoporosis, vertebral wedging (ie: Scheuermann's disease) etc etc etc?

>which makes the space all the shoulder tendons attach to the bone get >cramped and causes inflammation.

Yes. My future father in law had his shoulder scraped to alleviated just such a thing.

>The doctor said all movements where the upper arm goes over
>horizontal are detrimental.

There's more than one way to move your arms above horizontal. I know that sounds like crazy talk, but it's true non the less.

But it's almost impossible to explain via text ;-(

>And recommended I do different kinds of rowing exercises to fix my
>shoulder posture.

Do you have any paralysis or any of the disease mentioned above?

*Generally* Strength DOES NOT relate well to postural alignment

Here's a good article (in plain English) on the topic -

http://www.barrettdorko.com/a_big_mistake.htm

[L_J]

I think I might've been a bit too vague in my first post. I intend to follow my doctors advice and try to rehab my shoulder by strengthening my back, but I'd be interested in some advice about other kinds of stuff to do meanwhile since I'm very limited in upper body exercises.

I intend to keep doing BJJ and climbing, but I will be monitoring my shoulder and if it starts showing trouble I'll ease off.



Is there a medical reason as to why your shoulders are forward-alligned? Dowager's hump, Tuberculosis, ALS, Osteoporosis, vertebral wedging (ie: Scheuermann's disease) etc etc etc?

Not very likely. I've never had any serious medical problems and the X-rays on my shoulders are clean. So strength inbalance was the probable cause.



>The doctor said all movements where the upper arm goes over
>horizontal are detrimental.

There's more than one way to move your arms above horizontal. I know that sounds like crazy talk, but it's true non the less.

But it's almost impossible to explain via text ;-(

*Generally* Strength DOES NOT relate well to postural alignment


If at any point you are able to further explain what you mean with all that, I'd be very interested in hearing about it :)

[bob_stra]

>If at any point you are able to further explain what you mean with all
>that, I'd be very interested in hearing about it :)

I'll try.

Research over that past...oh...20yrs (depends how & where you look), shows that there is very little strength needed to maintain "posture". The article I recommend gives some more recent examples.

Infact, IIRC, Chaitow places the figure at 20% of maximum "contractile ability". In other word, unless there has been some catastrophic injury to tissues (nerves, muscles, ligaments) strengthening exercises do little to alter the posture permanently. I would argue that even then, a decent component of recovery is the reestablishment of neural pathways / reinnervation.

Posture in fact is a combination of two things - structural alignment and acture (ease of movement / grace / flow). Let's ignore the latter for a moment.

(excluding above mentioned pathologies)

You could argue that you get misaligned if a certain muscle overpowers another. Yes, you can. So you stretch that muscle. What happens? After a while, the muscle returns to its habitual place. This is one of the reasons why massage therapy is not longer lasting (for this class of problems)

Realistically, you could equally well argue that people develop a pattern of use that causes some muscles to overactivate and others to under activate.

This brings us to the critical juncture. It is my belief (backed up by the research and my own experience) that it is better and longer lasting to readjust the pattern of body use, rather than try to *force* the body to do something. In fact, the body tends to resist any forced changes.

To get to the nitty gritty of this is not a process for everyone. It's difficult. It takes time. So, physical therapists, being the pragmatists that they are, came up with short cuts and sneak around methods.

Eg - one of the reasons why light Theraband exercise are used vs heavier weights is to illustrate the pattern of use. Think of this way - you're holding a 20kg dumbbell, with your eyes closed. A fly lands on the dumbbell. Do you notice it - probably not. Now replace the dumbbell with the feather. I bet you notice it now ;-)

However, this needs proper instruction. Unfortunately, folks take this into the "more is better" realm. More weight, more reps, more time. In the end, more becomes less.

Now, that's the "poetic" version of it. I'm busy for the next few weeks, but, when I get back, if you're still interested, I'll give you the hardcore scientific version. (be careful what you wish for :-) It would take quite some time to get all the references together. Hell, I might add it to the "article to write for CST mag" list. Maybe.

In the mean time, any and all of the following will be of interest -

http://www.nas.com/~richf/pastlow.htm
http://www.somatics.de/ArticlesNorm.html
http://www.barrettdorko.com/articles/guard.htm
http://www.barrettdorko.com/articles/end_of_evaluation.htm
http://www.somatics.com/s-m-a.htm

Better still -

Pop down to the library and see if you can find "Elusive Obvious" or "Body & Mature Behavior - A Study of Anxiety, Sex, Gravitation and Learning". The author is Moshe Feldenkrais.

There's a nifty BodyFlow book out as well, I hear ;-) Can't recollect the author....hmmm.....

PS: There are legit PT's and DC's lurking here. Chime in please - your knowledge on these topics is much greater than mine.

PPS: None of this is meant as a poo poo on weight training or anything else. There's a tool for every situation.

PPPS: I'm just flapping my gums in the wind here. Listen to your Dr.

[rbibbs]

Footnote, Lauri. Climbing? First thing comes to mind is a preponderance of upper-body proximal flexion (and lower-body distal extension)... that's where the loads are. Could this result in an imbalance of tension, flexors hyperdeveloped relative to extensors? I had a friend, avid tennis player, hyperdeveloped calves, but his shin muscles were in constant pain from struggling against that imbalance.

I'm an engineer, by no means qualified to render medical opinions. Engineers have been wrong (think Chernobyl)... so have doctors (think bleeding). Both sciences are evolving, and current practioners may be on the leading edge, or the trailing edge, both fully licensed and competent, but with different results for a given situation.

As users of these professional services, we are the final arbiters of what's right for us, a difficult position for us since 'they' are much more knowledgeable. One way to partially offset that imbalance is to educate yourself to a practical extent, on the specific question you're facing (following Bob's links is a good place to start). And any time you're given a professional diagnosis or treatment plan with which you have lingering questions, seek a second professional opinion.

Rick

[Jarlo Ilano]

Bob wrote:

So, physical therapists, being the pragmatists that they are, came up with short cuts and sneak around methods.

I like that, because it is very true, the more I learn the more I realize that is exactly what therapists end up doing, because we only get maybe 8 visits with a particular patient. (and even less now, given the present state of healthcare.) I gave a lecture last year to P.T. assistants in my clinic and my friends, about this. I called it "playing the odds".

I am in a class right now where the training is osteopathic based. My instructor made the comment that the particular techniques we were learning were developed not from a particular theory but instead were based on trial and error, and kept because the osteopaths saw that they worked for a great majority of their patients. Then, one day, some guy asked them WHY do they work? Theories were then made after the fact in an attempt to explain them.

Perhaps other techniques/exercises/movements we use, were like this as well. Unfortunately, often these "shortcuts" are sometimes passed down, rather than genuinely explored and worked through by the therapists themselves. So, sometimes, you get a particular "recipe" that may not work for the individual. The therapist must be vigilant.

With that disclaimer, and also that you should not go against your physician's orders. Here is a good "sneak around method" that may help your shoulders in the short term.

Soft tissue your pec minor, subscapularis, subclavius, levator scapulae, and upper trapezius. Then stretch them out, then actively contract them through as full range of motion as you can. It's difficult but I'll try to explain how to do this.
Pec minor is under pec major. Some people go underneath the pec major from the side (be up fairly high into the armpit and go as far in as you can). You can also dig in through the pec major (my friend does this effectively). Hard to stretch specifically by yourself. Lay on your back with your hand behind the small of your back, have someone push the front of your shoulder down to the ground. After that go through a good range of motion.

Subscapularis is on the anterior (front) portion of the scapula (shoulder blade). Go up in the armpit and try to dig in the front of the blade. Also hard to stretch by yourself, you are going to have to find a way to flex your shoulder while keeping the scapula stable. Range of motion is reaching up to the sky.

Subclavius is right under your clavicle (collarbone). Dig around there. Range of motion is rotation of the clavicle, this appears in all shoulder ROM.

Levator scapulae and upper trap are on the top of your shoulder blade up into your neck and head. You will definitely find tender spots with no problems there. Stretch is sitting in a chair and holding on while you tilt your head (various directions, you choose the greatest stretch). Shrugs are the ROM along with all shoulder motions.

You can get someone to dig in to those muscles, there will be tender spots, those are the ones to work on.

Or you can get your doctor to refer you to a good P.T. =)

The reasoning behind this protocol is not that complex (I think), but it would take a while to explain in this format.

This is a recipe I've developed based on my great instructors, my colleagues, and my own experiences. It has worked well for the majority of shoulder "impingement" syndromes.

With that said, try at your own risk, and never without a physician's permission. In fact I hesitate to post this... oh well.

Jarlo