Brian Schiff’s Blog

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.

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One of the most common issues I see in the clinic with active exercise enthusiasts between the age of 20 and 55 is shoulder pain. Weightlifting has been popular for ages, but Crossfit is all the rage these days.  Both disciplines involve overhead lifts. The key thing to remember when performing overhead repetitive lifts is how load and stress not only affects strength and power, but how it impacts the joint itself.

Pull-ups and pull-downs are staples for most clients I see.  As a therapist and strength coach, I am always thinking and analyzing how variables such as grip, grip width, arm position, scapular activation, trunk angles etc influence exercise and how force is absorbed by the body.  One such exercise I have spent time studying and tweaking is the lat pull-down.

Consider for a moment how width and grip impacts the relative abduction and horizontal external rotation in the shoulder at the top and bottom of the movement in the pictures below (start and finish positions are vertically oriented):

It should be common knowledge for most, but I will state it for the record anyway – you should NEVER do behind the neck pull-downs.  Beyond the horrible neck position, this places the shoulder in a dangerous position for impingement and excessively stresses the anterior shoulder capsule.  A wider grip (be it with pull-ups, pull downs, push-ups) will always transfer more stress to the shoulder joint because you have a longer lever and greater abduction and horizontal external rotation.

So, what bearing does this have in relation to the rotator cuff and SLAP injuries?  For more information and details on the application of the grip choice, click here to read the full column I did for PFP Magazine this month.  Stay tuned for my next post (a follow-up to this one) one of my Crossfit patients who now only has pain with overhead squats and how my differential diagnosis and rehab has led me to conclude what is wrong with his shoulder.  Keep in mind we must learn to train smarter so we can train harder and longer without pain and injury.  Biomechanics and understanding your own body really does matter.

By far the most common problem I see in the clinic is shoulder pain. Most of the time it is related to overuse, rotator cuff tendonitis/impingement and labral tears. Because we are geared more toward sports rehab, I also treat a lot of overhead athletes (baseball players, volleyball players and swimmers).

A common thing I will see in those suffering from impingement or rotator cuff pain is scapular winging. Most of the time the muscle is simply deficient in strength/endurance and it along with the lower trap become overpowered by the upper trap, levator or even the rhomboids. Shortened scapulohumeral muscles, poor posture and pec tightness can also impact winging.

There are many traditional exercises such as serratus punches, push-ups with a plus, and serratus plank push-ups to name a few, but I wanted to include a closed chain exercise that can be very effective for facilitating proper activation of the serratus – quadruped rocking.

In the video, I show it with both hands fixed on the floor progressing to one hand (on the involved side). The key is quality of movement throughout. After you check out the video, be sure to scroll down and click the link to a full column I wrote for PFP magazine on this exercise as it further explains the technique and application.

Click here to read the online column for PFP Magazine.

This post is a follow-up post to one of my previous ones, A Closer Look at Push-ups & Modified Push-ups, based on some dialogue with a reader. Click the link to familiarize yourself with the background.  Some people simply do not agree with my assertion that modifying and or limiting end range of motion with certain exercises such as bench press, push-ups and flies is needed to preserve shoulder health long term.

So many people want to hitch their wagon to “simply strengthen the scapula” as a fix all solution.  While I agree 100% that scapular stabilizer and cuff strengthening goes a long way, we would be foolish to ignore joint biomechanics, physics and kinesiology when examining how loads affect joint structure and function over time.

I will start out by saying I ascribe to the idea that a healthy joint should be able to move through full range of motion.  My question to you is with how much load and how many times over and over again before destructive microtrauma sets in.  With that said, how many healthy shoulder joints do you think are working out in gyms across the world today?  Without an x-ray, it is impossible to know if you have a type I (normal), II (flat) or III (hook-shaped) acromion.  Your genetics do make a difference in your risk for developing shoulder problems, as types II and III are more prone to impingement (see photos below)

This is one risk factor that cannot be mitigated by prehab if you will.  I would also challenge you to consider that loading the shoulder repetitively with heavy loads in the furthest depths of shoulder horizontal abduction (bar touching the chest in bench press or lowering DB’s well below the plane of the body with flies) will eventually create atraumatic shoulder pathology.

Ever wonder about things like:

• Osteolysis of the distal clavicle
• Anterior shoulder laxity (over stretching the anterior capsule and joint structures over time)
• Creating impingement with repetitive motion in the presence of poor bony architecture, a thickened bursa or inadequate shoulder stability

While some may argue lifting does not create instability (it is known that bench press may lead to subtle posterior instability over time), I don’t think we can question the impact of weight lifting on clavicle destruction.  Men more commonly develop acromio-clavicular arthritis, and osteolysis of the clavicle is common with lifting exercises such as bench press, dips and upright rows.

Click here for an article discussing osteolysis of the clavicle. The authors specifically mention modifying or avoiding certain weight lifting techniques base on pain and radiographic findings.  I think we must as fitness professionals, strength coaches and educators look at the long term implications of lifting techniques on long term shoulder health and function.

Most would not hesitate to say they would do anything to avoid shoulder surgery if they knew their exercise habits might pose a risk for a future procedure to alleviate pain and restore function.  I firmly believe avid recreational weight lifters and bodybuilders should modify range of motion with many of these pressing and lifting motions to be safe.  This includes blocking full range bench press, modifying flies and push-ups, avoiding deep dips and generally minimizing how often they choose to do dips and upright rows. I also feel most people over age 35 or 40 should minimize the frequency of dips and upright rows as risk outweighs reward over time with repetitive loading of the clavicle (particularly if they have a long history of weight lifting already).

Take a look at the x-ray below showing osteolysis.  You can often see a widening at the AC joint.  Many times, these patients must undergo steroid injections, rest, activity modification and even a distal clavicle excision to resolve the pain.

Call me conservative or crazy, but  I know personally how limiting bench press/fly range of motion eliminated my cuff pain in less than 2 weeks years ago when I was in college.  Additionally, I currently have two patients in  my clinic with shoulder injuries:

1. A 19 y/o male hurt doing submax loads full range with a barbell
2. A 60 plus y/o male who had arthroscopic repair of a torn supraspinatus that occurred while doing dumbbell flies (submax loads) on a flat bench lowering the dumbbells far below the parallel

Two patients decades apart hurt by the same mechanism – a biomechanical mismatch and repetitive microtrauma.  So, my own body, years of clinical and training experience, and research studies have led me to conclude that modifications for those choosing to do resistance training 2-3 plus times per week for many years on end are necessary to have healthy shoulders for years to come.   If you value your shoulder health and that of your clients, consider restricting depth, reducing shoulder abduction angels with pressing and carefully selecting and or limiting certain exercises based on client medical history and functional goals.

I am sure you or someone you know has suffered with or been affected by a frozen shoulder at some point.  Known in the medical world as adhesive capsulitis, this condition can be downright miserable for folks.

Who gets it?  It is often brought on after injury or a period of immobilization (e.g. arm in a sling after surgery or dislocation).  However, it also comes on insidiously too.  Statistics indicate it more commonly affects women and those with diabetes are at more risk for getting it in both arms.

Some feel it may ultimately be an autoimmune reaction that triggers it.  So, what is it exactly?  Well, in plain terms your shoulder joint has folds of connective tissue we refer to as a joint capsule.  In frozen shoulder cases, the capsule becomes shortened and inflamed making arm movement painful and limited at best. 

There are three distinct phases:

1. Freezing
2. Frozen
3. Thawing

These phases may progress over the course of months or in some cases last as long as 2-3 years to resolve.  In time, the condition will correct itself. 

Symptoms may include:

• Stiffness
• Difficulty sleeping
• Pain along the shoulder or down into the arm
• Certain movements more restricted than others
• Progressive worsening of motion and decreasing pain

No one wants to suffer with this for any prolonged period of time.  So, how do you accelerate the healing process?  You must move the shoulder daily within your available range of motion.  But doing the right exercise is critical.

In addition, I believe having an experienced therapist do joint mobilizations is critical in loosening up the capsule provided it is done within pain tolerance of the patient and followed up by appropriate stretching.  For those without insurance or looking to avoid the grueling stretching some docs and PT’s advocate, I recommend looking at my home therapy guide.

Want more info?  Visit www.frozenshouldertherapy.com for success stories and more details on my proven home remedy.  You can also click on the image below:

In addition, I think you can complement rehab with a tool like the Rotater to help restore mobility.  I have trialed this product myself and I really like the ease of use and control the patient has with the stretching intensity.  For more details, click on the image below: