So, I treat a number of fitness enthusiasts in the clinic and many include Crossfit clients. Recently, I evaluated a 38 y/o male on 2/16/12 with a 3 month history of right shoulder pain. He performs Crossfit workouts 6 days per week. His initial intake revealed:
- Constant shoulder pain that worsens with overhead movements
- Pain with bar hangs, overhead squats and wide grip snatches
- Unable to do kipping (only doing strict form pull-ups)
- Pain if laying on his right side at night
- No c/o neck pain, referred pain or numbness/tingling
Notice the shoulder position during the kipping pull-up and overhead squat below. This is a position of heightened risk for the shoulder.
His exam revealed the following:
- Normal range of motion
- Strength within normal limits except for supraspinatus and external rotation graded 3+/5 with pain
- Positive impingement signs
- Negative shrug sign
- Negative Speed’s and O’Brien’s test
- Tender along distal supraspinatus tendon
Based on the clinical exam, it was apparent he had rotator cuff inflammation and perhaps even a tear. Keep in mind he had not seen a physician yet. I began treatment focused on scapular stabilization and rotator cuff strengthening as well as pec and posterior capsule stretching to address the impingement. Ultrasound and cryotherapy were used initially to reduce pain and inflammation.
One month following the eval
By 3/14/12, his pain was resolved with daily activity and he had returned to snatches and push-press exercises without pain. He still could not do overhead squats with the Olympic bar pain free, but he could with a pvc pipe. Strength was now 4/5 for supraspinatus and 4+/5 for external rotation. All impingement tests were now negative as were Speed’s and O’Brien’s testing.
Six weeks following the eval
By 4/2/12, supraspinatus strength was now 5/5, while external rotation strength was still at 4+/5. My patient could now do some light kipping pain free but was still unable to do overhead squats. All signs of cuff inflammation seemed to be gone. My suspicions of a cuff tear were fading fast. But why did OH squats still causes so much pain with the elbows locked out? My client told me he actually felt less pain if he forcefully internally rotated the shoulder moving to a more pronated grip (opposite of proper form) and not the position that would avoid shoulder impingement.
As I dug further into his mechanics and had him adjust grip and rotation, he indeed had more pain with a wide traditional grip and alignment. I once again checked his O’Brien test and now it was positive. This clinical test does not have great sensitivity or specificity according to all studies, so I never assume it is a “tell all” sign. Keep in mind it has been negative up to now. The major change at this point has been the resolution of cuff pain and impingement signs.
The other positive clinical finding today was pain along the proximal biceps tendon and anterior joint line. I then had an “ah ha moment.” The traditional position in the overhead squat (moving into full ER and abduction) was likely causing some torque on the proximal biceps anchor. It is possible that in addition to his rotator cuff inflammation, he may have suffered a SLAP injury. It could be a minor type I injury or more.
What next? I advised him of my clinical findings and that the only way to rule out a SLAP tear would be an MR arthrogram. He was pleased enough with his recovery at this point that we agreed he will continue with his rotator cuff and scapular strengthening program at home while simply avoiding overhead squats for now. As a self employed attorney, he is not in a big hurry to entertain a potential procedure for a labral injury if the only thing he cannot do at Crossfit pain free is OH squats.
- Resolution of pain/inflammation and quick return of strength indicates pain inhibition from tendonitis more so than a cuff tear in this case (keep in mind nocturnal pain also resolved in less than 4 weeks)
- Full abduction and external rotation (with more relative supination) in the overhead plane should hurt less than internal rotation and pronation in pure cases of impingement (allows greater tuberosity to clear the acromion)
- It is entirely possible to have both rotator cuff and biceps tendon/labral issues at the same time
- Clinical testing is not always sensitive and specific enough to tell the whole story
- Biomechanics and proper analysis of lifting technique provides valuable clues to the tissue at fault
While I do not have MRI or MR arthrogram findings to definitively support my assessment to date, I am fairly confident this gentleman was suffering from rotator cuff inflammation/dysfunction and a probable labral injury. Perhaps all the overhead work has created a subtle anterior instability thereby leading to some contact between the cuff and the posterior superior labrum as well as resulting in some torque on the biceps anchor over time and with this overhead position. It is plausible that he is/was experiencing internal impingement much like a pitcher does. Hopefully, he can resolve and manage his symptoms with his home exercise program moving forward.
Regardless of the exercise in question, we must always keep in mind that injury risk is directly impacted by muscle imbalance (stress chest/posterior shoulder capsule flexibility), poor muscle activation (engage lower trap and serratus anterior while improving rotator cuff endurance) and overuse training (closely examine volume and recovery cycles). Prior to jumping in to Crossfit (or any vigorous exercise routine), I strongly suggest getting a screen by a professional to assess and address any muscle imbalances that may predispose you to an injury. Remember that training through shoulder pain will only lead to prolonged pain, dysfunction and more damage in the long run.