Brian Schiff’s Blog

Ever feel the tightness or ache deep in the shoulder during or after a series of bench press sets?  I must admit I LOVED doing bench press all through college and in my early twenties.  Guys love the chest pump and of course nothing impresses a girl more than broad shoulders, a big chest and beefy arms, right?

Then as I began gaining years of experience as a therapist and started my personal training career, I began to realize a common scenario in men lifting weights regularly.  They had horrible posture, weak posterior chain strength and sore shoulders.  The common thread was this:

• Bench press and loads of chest exercises 2-3x/week and maybe some occasional back exercises thrown in once per week. 

This repetitive bench pressing, dips and flies created a HUGE imbalance.  Keep in mind for every chest exercise you do, you should balance it with a back exercise.  Some believe the ratio of back to chest exercises should be 3:2, while others suggest 2:1.  Suffice it to say I just believe we need less pressing and flies and more back exercises in general.

The poor weak rotator cuff stands up tall in the teens, twenties and early thirties, but it eventually starts to break down over time.  Aside from modifying range of motion, load and changing arm angles (all things I preach), you must work hard to reverse the effects of gravity by doing more upper/lower back training to prevent the caveman syndrome.

Your long term shoulder health depends on it.  I have rehabbed hundreds of shoulders going through rotator cuff and labral repair that are no doubt in some way related to lifting abuse.  Take my word for it when I tell you backing off the load, volume and frequency of bench pressing will add years of life to your shoulders and prevent you from living on anti-inflammatory medication to make it through the day.  I am not anti-bench per se, but I do believe once per week is more than enough for most of us.

Today, I have included a link to a recent column I wrote for PFP Magazine on one such posterior chain exercise to work the upper back and cuff.  Click here to read the column.

In addition, I added a video of the exercise below.  This is easy to do and will immediately improve shoulder health.  Consider adding it to your gym routine at least 2x/week on upper body days.

In closing today, I want to wish all of my friends, family, subscribers and followers a Happy Holiday Season!

If you have ever experienced shoulder pain (whether sudden or chronic) you have probably heard people or docs throw out the terms tendinitis, bursitis, or partial and full thickness tears.  In this post, I will attempt to summarize these and delineate as best I can between the symptoms you may experience.

Bursitis – inflammation of the subdeltoid bursa (fluid filled sac) beneath the deltoid.  Bursae are in place to cushion the soft tissue and prevent rubbing or friction.  They lie between tendon and bone or between the tendon and skin.  In the shoulder, signs of bursitis include:

• Pain and tenderness along the upper arm with radiating pain down the to the elbow in many cases
• Pain lying on the affected shoulder (esp. at night)
• Pain with repetitive motion (especially overhead and behind the back)
• Warmth and swelling along the middle deltoid

Tendinitis – the tendon itself becomes inflamed and swollen (usually the supraspinatus) and may become trapped or start rubbing beneath the acromion (top of the shoulder blade) and then becomes an impingement problem (known as impingement syndrome).  Pain may also be felt along the biceps tendon as it may undergo undue stress and strain in relation to a cuff issue.  It is also important to note that bursistis often accompanies tendinitis.  Typical symptoms include:

• Point tenderness at or near the top of the shoulder or over the biceps tendon as it meets the shoulder
• Pain and joint soreness along the front of the shoulder
• Pain that worsens with elevating the arm above 90 degrees or moving it away from or behind the body
• Pain with lying on the affected shoulder
• Pain tucking in your shirt, fastening a bra or styling your hair

Tear – defined by a disruption in the quality or integrity of the muscle and or tendon.  Tears are typically quantified by the location (articular or bursal side) size (in centimeters) and degree (partial or full thickness).  Not all tears are created equal – that is a fact.

I have seen small tears (less than 1-2 cm) create equisite pain and dysfunction, while large tears (greater than 3 cm) may produce less pain and limitations in daily activities for folks.  Hallmark symptoms of a tear include:

• Pain at night that interrupts sleep
• Persistent dull ache or even throbbing pain that is not affected by rest or positional changes
• Significant weakness or even muscle atrophy (look at the shoulder blade from behind or int he mirror)
• Loss of elevation and arm rotation overhead and behind the back
• A positive shrug sign (see below as excessive upper trap work that compensates to elevate the arm in light of a torn rotator cuff muscle)

Positive Shrug Sign

Some research suggests up to 90% of tears will worsen over time.  Tears do not spontaneously heal.  With that said, many respond well to conservative rehab with an emphasis on restoration of motion, appropriate strengthening and avoidance of abusive activity.

The prescription for healing bursitis and tendinitis is much the same.  However, catching the “itis” early on and using ice, rest and anti-inflammatory medication as prescribed can often cure it in weeks and prevent further damage.  Pain shouldreally guide all activity and exercise progression.  The other forgotten friend is ice – whether acute or chronic I advise daily icing for pain relief.

Want more answers to rotator cuff issues?  Visit my site at www.rotatorcufftraining.com.

Wow, it has been a while since I posted.  After battling what may have been H1N1 for nearly 2 weeks I am back at it.  I just returned from the Sports Physical Therapy Section Meeting in Las Vegas held last weekend.  All the brightest minds in the industry were there covering the latest research with an emphasis on knees and shoulders this year.

I must say I came away most impressed with Dr. Scott Dye.  He is an orthopedic surgeon at the University of San Francisco, CA.  He spoke on several topics but continued to highlight this concept of respecting the “envelope of function” in regard to activity and healing.  It really resonated with me as it sounded a lot like my concept of threshold training.

He believes we have a set envelope of function, if you will, that predetermines how much stress our body will absorb before breaking down.  There is the natural envelope and then an area he termed “supra physiologic load.”  Once we break this barrier of supra physiologic load, then mechanical tissue failure ensues.

He preached using bone scans as a diagnostic tool for measuring whether your body was really at tissue homeostasis as opposed to still being inflamed.  His assertion is that often we push people back to full activity too soon based upon subjective reports of no pain and clinical tests as opposed to measuring the joint itself with a scan to see if it is still reactive.

He raised a few eyebrows when he suggested that he does not let athletes return to play after ACL reconstruction until somewhere near 18 months.  While that may seem crazy, he had some interesting research he has done to show how his post-op patients do not get early arthritis at follow-up as far out as 15 years after surgery. 

In essence, he explained that we as practitioners must progress rehab and training in a very sequential and client specific way based upon this envelope of function theory.  While I am not sure I bought  his rehab time lines lock, stock and barrel, I do believe he is right on track with this envelope of function idea.

I have been saying for years that pain is not a good sign during training or rehab.  My critics have often said you can push through some pain with frozen shoulder, rotator cuff pain and the likes with training in order to move forward.  I have always countered that your body has a threshold to activity.  The only surefire way to progress without re-injury is to adequately gage and understand the threshold level, while adding stress to the system only as able while staying within the threshold.

How do I measure the threshold?  I have included my basic definition below:

With a proper training threshold, the athlete or client learns how to grade and evaluate the stress on his/her body during every practice/training session, while gaining an understanding of the exact threshold itself.  The threshold (activity tolerance level) should increase or progress with subsequent training, and the use of pain or soreness in response ot said stress should be the guiding factor in adding more load or volume.

Key parameters to track include:

• Pain at rest or before activity
• Pain during activity
• Pain after activity
• Length of time for pain (if present) to resolve or return to baseline

Teaching athletes and clients to track and understand this concept is critical to long term health.  First, you must get them to honestly report their symptoms.  Then, you must earn their trust by reassuring them your goal is to return them to full activity as soon as possible but as safely as possible.  Finally, you must implement the system and relate it to the exercises for them to understand how to measure their body’s response.

As I work with elite level athletes and everyday folks struggling with SLAP tears, rotator cuff impingement and knee arthritis to name a few, I become more convinced that accurately gaging their threshold or envelope of function is the key component when it comes to successful exercise program design and progression.

So, I recently blogged on platelet rich plasma (PRP).  I wanted to provide you with the latest up to date info on this procedure in regard to chronic tendinitis.  Many people suffer from lateral epicondylitis (tennis elbow).  This is a condition that affects the extensor tendons in the elbow.  Most experts link tendon injuries to hypovascularity (not enough blood flow) and repetitive micro-trauma thereby resulting in localized weakness and degeneration over time.

This may lead to eventual rupture but no one can predict that for sure.  Using PRP would hypothetically reverse the effects of chronic tendinopathy while stimulating healing at a microscopic level by initiating revascularization.  The info and data for this post was in large part taken from the American Journal of Sports Medicine (Nov. 09).

It is important to keep in mind if you are dealing with tennis elbow to understand the difference between acute injury and chronic pain.  Physiologically, healing enters the chronic phase in 22 days post injury.  However, from a clinical perspective, a physician may not consider elbow tendinitis chronic until after 3 months or more in some cases.  While PRP has shown positive results in several small case studies, the abundance of solid research is still lacking or too small to draw finite conclusions as to its efficacy.

With that said, let me share some data for people who were treated for tennis elbow with PRP:

• Mishra & Pavelko treated 20 patients out of a sample of 140 with elbow pain who met their inclusion criteria.  Of those 20, 15 were given PRP and 5 served as controls receiving only local anesthetic injections.  The PRP group noted a 60% improvement at 8 weeks, 81% at 6 months and 93% at the final follow-up (range b/w 12 and 38 months).  However, 3 of the 5 controls withdrew from the study early to seek other treatment which means the data can only be drawn from the PRP group.  Although flawed with a small group and attrition in the control group, this study was prospective and did include a control group.

What does this mean?  Well, if you have ever suffered from lateral epicondylitis or worked with those that have, you know how difficult this condition can be to resolve.  I know several people that opted for surgery to end the pain.  Conservative treatment often consists of ice, rest, stretching. strengthening and cross fiber massage.  Some use a Band-it brace and acupuncture as well.  In the end, it can be down right debilitating.

PRP may provide a better answer, but more research and larger trials are needed to confirm the overall efficacy of it.  If you are a chronic sufferer though, you may want to seek out an orthopedist who is proficient in this and take a look.  Aside from tendinitis, the effects on muscle strain, ligament tears and bone are also being studied.  High level athletes are using PRP to get back to play faster as one unpublished study with professional soccer players suffering grade II MCL injuries reports a 27% faster return to play after injury compared to controls when injected with PRP within 72 hours of the injury.

In the end, the optimal dosage and use of PRP has yet to be defined.  But it may certainly signal a new era of treatment of soft tissue injuries and speed the recovery from such injuries.

So, one of the newest treatments being touted in the sports medicine arena is platelet rich plasma (PRP) therapy.  What is this exactly?  It is not an easy thing to explain in plain terms, but here goes my best attempt.

Platelets help the repair process in the body as they contain growth factors like platelet derived growth factor (PDGF), transforming growth factor (TGF)-ß, insulin-like growth factor (IGF) and fibroblast growth factor (FGF) to name a few.  Upon activation, these factors are released and sent to aid the injured site in healing.  In this therapy approach, a centrifuge is used to increase concentration the concentration of platelets.  PRP has up to 8x the concentration of platelets that whole blood does.

The PRP is then usually injected into the injury site.  This is commonly being used to treat ligament sprains such as an MCL sprain in soccer players.  A recent study was released in the American Journal of Sports Medicine in March 2009 in regard to the effects fo PRP on muscle strains.  Muscle strains are largely considered the primary injury in sports medicine today (think about hamstrings, quadriceps, groin and calf strains to name a few).

Keep in mind muscle injuries typically occur when the muscle is lengthening under tension (eccentric contraction).  Why so?  In eccentric contractions the muscle force produced is approximately twice that of a maximal isometric contraction (max muscle force against static resistance without motion).

In this study, researchers looked at rats and induced a muscle injury to the TA (tibialis anterior muscle) in one of two ways: Group A underwent a single eccentric (lengthening) injury over a 90 degree arc of motion, while Group B underwent 45 smaller strains over a 60 degree arc to simulate more of a chronic muscle strain as opposed to an acute injury in Group A.

To summarize the results, researchers found that the PRP had little effect on Group A other than to noticeably affect force production in a positive way on day 3 post-injury.  They are unsure if this is simply due to reduced inflammation (PRP should help with this).  Otherwise, full force production with the single acute strain was back in 7 days relative to pre-injury levels whether using PRP or not.  However, in the repetitive or chronic strain group (group B) the PRP had significantly positive effects at day 7 and 14 and led to a faster overall recovery.

Does this mean we should use PRP on all muscle strains??  Not so fast.  What is clear are that injuries in need of myogenesis (muscle rebuilding) are better candidates for this therapy.  The tricky part is the great degree of variability in muscle strains and determining if the science is transferable from the rat to human model.  In the end, the treatment is promising as there appear to be no harmful side effects, but further research will be needed to validate the impact on healing tendons and muscles alike.

Also keep in mind that progressively rehabbing the injured part with systematic eccentric loading to restore the tissues’ threshold to stress is necessary to accurately gage response to functional mechanical loads.  My hope is that this procedure will be used in conjunction with rehab to speed healing and get athletes back on the field faster.  Its greatest use may come in dealing with chronic tendinitis or partial tears.  Only time will tell, so stay tuned.