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Thread: Shoulder impingement and training

  1. #11
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    Quote Originally Posted by SilverStar View Post
    Surgery doesn't mean improved outcomes. It's entirely possible you'll have less range of motion afterwards after rehabilitation, or still have pain in the shoulder. It's a bit irresponsible for the orthopedic surgeon not to recommend physical therapy as conservative treatment, especially since it looks like it's a pretty mild tear. Surgery in this case is going to be bit of a gamble that it'll turn out the way you want, and the initial choice should be physical therapy, and if it doesn't work, then look into surgery. I would see a sports physical therapist. Maybe there's a physical therapist registered with clinical athlete near you.

    I see a fair amount of patients that are post-OP RC repair and they sometimes never regain their full range of motion overhead, especially with certain surgical techniques.

    It's pretty common to get patients with similar presentations like this and then with some treatment they get greatly reduced pain and full function. Rotator cuff tears, especially mild ones, are very common, and aren't really well correlated with pain and loss of function. It's entirely possible it's an old injury and for some reason or other you started developing pain in the shoulder.

    Researching is good and all, but it doesn't replace having a healthcare professional diagnosing and treating you. The physical therapist is going to have the research knowledge...plus years of education and experience. Researching and then trying to do it yourself is a risk, and given it's your shoulder I wouldn't gamble on that unless you have significant financial concerns.
    Thank you for the information. I should have mentioned in my op that I did do a round of physical therapy last April (for a few weeks), but I did not see much improvement.

  2. #12
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    Not sure that it matters in the larger picture, but it’s my supraspinatus tendon that had 6 mm interstitial tear, not the infraspinatus as I mentioned in my op. The infraspinatus has mild tendinosis without tear.

    I think that I am going to spend some time just trying to rehab my shoulder, and back off from the training. But, it’s hard for me to not be active. Is It really doing a lot of damage for me to do pulls, cleans, etc., if I don’t feel any pain when doing them. Sorry if I am coming off as a hard-head,! I just really don’t know much about these things.

  3. #13
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    Quote Originally Posted by jackie View Post
    Not sure that it matters in the larger picture, but it’s my supraspinatus tendon that had 6 mm interstitial tear, not the infraspinatus as I mentioned in my op. The infraspinatus has mild tendinosis without tear.

    I think that I am going to spend some time just trying to rehab my shoulder, and back off from the training. But, it’s hard for me to not be active. Is It really doing a lot of damage for me to do pulls, cleans, etc., if I don’t feel any pain when doing them. Sorry if I am coming off as a hard-head,! I just really don’t know much about these things.
    None of the rest of this post is meant to be medical advice for you. This is me giving medical advice for a theoretical patient.

    If it doesn't cause pain for the theoretical patient, then it's fine. If it causes pain with a classic lift, then don't do it. I would avoid higher %'s on the classic lifts. Pulling is fine, I would want the theoretical patient to brace the upper back, and immediately stop if there's any pain.

    Erdman is right that loading is key. Now that you said it's the supraspinatus and not infraspinatus, I would start with exercise 1 that he mentioned, and see how they feel. If it's painless or the pain is a 3/10 at the most and the soreness/pain goes away, then the weight can be increased. It's better to be safe than sorry, so I would want to increase by like 0.5kg each time.

    Very importantly, with a mild supraspinatus tear and infraspinatus tendinopathy, I would watch to check your thoracic mobility, scapula biomechanics, and scapula stability.

    For this theoretical patient, improving scapula biomechanics and stability will relieve a lot of stress for the rotator cuffs and can be beneficial for long-term healing and injury risk reduction. I would also check teres major, lats, teres minor tightness as well, as the rotator cuff likes to compensate for deficits in other areas and this places stress on the rotator cuff muscles.
    Last edited by SilverStar; 09-09-2019 at 01:51 AM.

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  5. #14
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    Quote Originally Posted by jackie View Post
    Thank you for the information. I should have mentioned in my op that I did do a round of physical therapy last April (for a few weeks), but I did not see much improvement.
    There's a wide variety of physical therapists with different skillsets. Most patients are general population, and have different needs compared a more strength oriented person. That physical therapist's skillset may not have matched your needs.

  6. #15
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    Quote Originally Posted by SilverStar View Post
    Exercise 1 won't target the infraspinatus very well, as the infraspinatus is mainly an external rotator. While your shoulder will externally rotate if you keep it thumbs up in scaption (which is the motion you're describing) it's going to be a secondary thing. Exercise 2 is a similar issue, assuming if I understand the exercise correctly. It will mainly target your shoulder adductors.

    Both of those exercises will provide benefits in the sense of overall shoulder/glenohumeral shoulder stability, which can potentially help your shoulder pain. It just won't directly target the muscle/tendon involved.
    Being an isometric exercise, I think all relevant muscles and tendons are under significant tension. Training the muscle is not the goal here. The muscle doesn't have to get stronger for collagen synthesis to be stimulated. After the issues mentioned start clearing up, there could definitely be value in hitting different exercises with isokinetics.

  7. #16
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    Quote Originally Posted by Matt Erdman View Post
    Being an isometric exercise, I think all relevant muscles and tendons are under significant tension. Training the muscle is not the goal here. The muscle doesn't have to get stronger for collagen synthesis to be stimulated. After the issues mentioned start clearing up, there could definitely be value in hitting different exercises with isokinetics.
    I disagree. With the scaption raise, the primary muscle under tension is going to be the supraspinatus, with the other muscles receving secondary loading. For better loading for infraspinatus tendon, exercise 2 would have been appropriate as a stabilizer.

    Nothing I described is for muscle strengthening, it's for tendon loading. Second, isometrics are generally indicated for sub-acute or soon after the initial event. With Jackie's description "for the better part of a year", it sounds chronic. With chronic tendon injuries, eccentrics are generally indicated over isometrics, although it's not wrong to do isometrics, just not likely to be as optimal as doing eccentrics.

    Since Jackie said it was actually the supraspinatus, then the scaption raise would have been correct and appropriate.

    It's also possible I'm misunderstanding exercise 2. The description isn't very clear.

  8. #17
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    Quote Originally Posted by SilverStar View Post
    None of the rest of this post is meant to be medical advice for you. This is me giving medical advice for a theoretical patient.

    If it doesn't cause pain for the theoretical patient, then it's fine. If it causes pain with a classic lift, then don't do it. I would avoid higher %'s on the classic lifts. Pulling is fine, I would want the theoretical patient to brace the upper back, and immediately stop if there's any pain.

    Erdman is right that loading is key. Now that you said it's the supraspinatus and not infraspinatus, I would start with exercise 1 that he mentioned, and see how they feel. If it's painless or the pain is a 3/10 at the most and the soreness/pain goes away, then the weight can be increased. It's better to be safe than sorry, so I would want to increase by like 0.5kg each time.

    Very importantly, with a mild supraspinatus tear and infraspinatus tendinopathy, I would watch to check your thoracic mobility, scapula biomechanics, and scapula stability.

    For this theoretical patient, improving scapula biomechanics and stability will relieve a lot of stress for the rotator cuffs and can be beneficial for long-term healing and injury risk reduction. I would also check teres major, lats, teres minor tightness as well, as the rotator cuff likes to compensate for deficits in other areas and this places stress on the rotator cuff muscles.
    Thanks for the information. In theory, besides the first exercise that Matt suggested what other things could I work on? I was planning to do some in/external rotations, the YWT sequences, and so forth. Also, from reading another post of yours, it seems that you would favor eccentric-type exercises over isometric exercises. Is this correct? If so, do you have any exercises that you like to address my current situation? I'd like to give them a try over the next several weeks, along with Matt's exercise.

  9. #18
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    Quote Originally Posted by jackie View Post
    Thanks for the information. In theory, besides the first exercise that Matt suggested what other things could I work on? I was planning to do some in/external rotations, the YWT sequences, and so forth. Also, from reading another post of yours, it seems that you would favor eccentric-type exercises over isometric exercises. Is this correct? If so, do you have any exercises that you like to address my current situation? I'd like to give them a try over the next several weeks, along with Matt's exercise.
    For the theoretical patient, what you said would be fine eccentrics is correct, isometrics are more for patients that have a worse tear/more acute stage of condition/lack of physical activity before progressing to eccentrics. If you want to play it safe, doing it isometrically is fine, it's not going to hurt you or anything. I would also do L's, although this is optional. The general principles is 3-4x/week, 2-3 sets of 8-15 reps, no more than 3/10 pain during, and if pain after, it should go away within 24 hours. If it's still painful, don't do it until it calms down and do less weight. Careful management is important, progress is dictated by pain and function.

    I would also scapula stability exercises as well. Standing serratus anterior punches with the barbell overhead, with KB bottoms up while in bottom of squat (this also depends on your mobility, if you aren't able to do this well then dont), supine KB bottoms up serratus anterior punches, side planks with good scapula/shoulder stability, etc. I don't recommend doing pushup pluses though, it's far more common for them not to do them well and not even realize it.

  10. #19
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    Quote Originally Posted by SilverStar View Post
    For the theoretical patient, what you said would be fine eccentrics is correct, isometrics are more for patients that have a worse tear/more acute stage of condition/lack of physical activity before progressing to eccentrics. If you want to play it safe, doing it isometrically is fine, it's not going to hurt you or anything. I would also do L's, although this is optional. The general principles is 3-4x/week, 2-3 sets of 8-15 reps, no more than 3/10 pain during, and if pain after, it should go away within 24 hours. If it's still painful, don't do it until it calms down and do less weight. Careful management is important, progress is dictated by pain and function.

    I would also scapula stability exercises as well. Standing serratus anterior punches with the barbell overhead, with KB bottoms up while in bottom of squat (this also depends on your mobility, if you aren't able to do this well then dont), supine KB bottoms up serratus anterior punches, side planks with good scapula/shoulder stability, etc. I don't recommend doing pushup pluses though, it's far more common for them not to do them well and not even realize it.
    I meant to ask, for the standing serratus anterior punches with the barbell overhead, is this a press vertically upwards keeping my arms straight (like serratus pushups but vertical)?

  11. #20
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    Quote Originally Posted by jackie View Post
    I meant to ask, for the standing serratus anterior punches with the barbell overhead, is this a press vertically upwards keeping my arms straight (like serratus pushups but vertical)?
    Yes, but be aware of the distinction between shrugging up with your upper traps and vs SA to do it. It's important to not to be shrugging up with upper traps when you think you're using serratus to do it. It's okay if you're fully locked out and shrugged up then use serratus to punch up more. The main thing is you want to be able to have the muscle control to separate the two and know which you're using.

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