Shoulder Impingement Syndrome Part 2 – Treatment

In my previous post on Shoulder Impingement I discussed anatomy and causes of shoulder impingement. In this post we will discuss treatment and prevention.

TREATMENT 

We can treat the symptoms all we want but they will come back if we do not address the real cause of the problem. The shoulder really isn’t the problem. The shoulder pain/impingement is always a symptom of a larger issue. A more global look at the climber, their posture, muscle imbalances, and movement dysfunction are all important for better long-term outcomes.

1. Alignment 

By now you’ve heard of Climber Posture. Do you know any climbers that stand like this? Maybe you stand like this? Most of my climbers with shoulder impingement stand like this.

How many climbers do you know that stand like this? Maybe you stand like this.

I know, I know. Talking about posture isn’t sexy but just incase you think it doesn’t matter that much consider the following:

According to a 2014 study in the European Spine Journal a slouched posture reduced shoulder flexion and abduction.

Another study in 2005 in the Manual Therapy Journal found that a slouched posture reduced shoulder flexion by 18 degrees.

According to a 1999 study in the Archives of Physical Medicine a slouched posture reduced shoulder strength in abduction by 16.2%

This means that your posture could mean the difference between sending and not sending. It could even mean the difference between being able to a climb a V7 vs. V9/10 or V10 vs. V12/13.

That’s huge! Want to improve your climbing by 2 grades or more? Fix your posture!

These dudes could use a postural fix.

These dudes could use a postural fix.

With that said, the first thing I address in my climbers is posture and alignment. The alignment of the scapula will determine how much subacromial space we have. We also must realize that scapula position depends on rib position, rib position depends on spine position, spine position depends on pelvic position. It’s all connected.

The first thing we need to do for someone with this posture is assess thoracic spine mobility. The “back to wall shoulder flexion test” or the “wall angle test” can give us clues about how stiff someone’s thoracic spine is.

tsp

The thoracic spine.

The thoracic spine is normally pretty stiff in climbers because we use so much of the muscle in that area of our back. 13-15 degrees of thoracic extension is needed for full overhead elevation of the arms.

When I see climbers with impingement I always manipulate (adjust) the thoracic spine and ribs. Thoracic spine manipulation decreases sympoms of shoulder impingement by realigning the spine and rib position.

According to a 2009 study in the Journal of Manipulative Therapy thoracic manipulation resulted in 51% reduction in pain and 30 degree increase in shoulder elevation.

Bench T-spine Mobilization is a mobility drill I like to teach my climbers so that they can keep the thoracic mobility we gained from the thoracic manipulation.

Picture 12

Rock Back Quadruped Extension Rotation is another mobility drill I like that works on thoracic mobility.

Picture 13

Another more aggressive way to mobilize the thoracic spine is using a double lacrosse ball as shown here:

Thoracic mobility with double tennis ball or lacrosse ball. 

photo 1

2. Tissue Quality

The next thing I look at is tissue quality. Tight muscles can pull the scapula out of alignment and can prevent other muscles like the lower trap and posterior rotator cuff from doing their job.


levator_scapulae1347913240177

Tightness in the upper traps, levator scapulae and pec minor can affect scapula position.

Tightness in lats and teres major and pec major will affect the alignment of the humerus causing it to internally rotate.

Picture 17

Tissue and mobility work need to be done everyday.

 

“When it comes to mobility there are no off days.” -Dr. Kelly Starret, Becoming a Supple Leopard

To make change in the affected tissues consistent work must be done. It doesn’t have to take a lot of time. Fifteen minutes a day is enough.

Thoracic Mobility with a double tennis ball or lacrosse ball

Side Lying Windmill for Thoracic Mobility

Rock Back Quadruped Rotation

Teres and Lat Self Myofascial Release 

Pec minor Self Myofascial Release

3. Rehab Exercises

The point of rehab exercise is to reinforce correct movement patterns and climbing technique and address muscle imbalances. These exercises improve neuromuscular signaling and increase blood flow to the injured area which helps the muscles recovery after injury and reminds your brain to fire those muscles during climbing.

With that said these exercises are not the end of your strength training. Once we balance your cuff and lower traps we have to start doing strengthening exercises that incorporate these muscles into larger movement patterns. A post on this coming in the near future.

Here are some exercises I recommend:

A) We all love push ups for training opposition climbing muscles but it’s important to also do other pressing movements that more closely mimic climbing. Push ups are a good choice but landmine presses are better. They train the rotator cuff and they are in the same plane (overhead) that we typically do all of our pulling in climbing. Also, the half kneeling position gets the core involved.

Landmine Press

Landmine Press technique

B) Rotator cuff Exercises

“Doing rotator cuff exercises is like cleaning your gutters; it’s not sexy or fun, but you need to do it or else bad things will happen. ” -Eric Cressey

You heard that, right? Bad things will happen, like having to cancel your bishop trip cause your shoulder is hurting. No one wants that. Especially six of your friends who you were planning to split gas and a hotel with.

“JUST DO IT!” -Nike

Side-lying External Rotation

Half-kneeling Cable External Rotation (more advanced, only do this one if it is non-painful and non-pinchy)

C) Rows

Everyone knows it’s important to do rows for scapular stability in your training program. However, many people don’t realize that you only get the benefits of all these rowing exercises if you actually perform them with correct technique!

Check out this detailed video on all the common mistakes we see with my favorite variation, the standing 1-arm cable row:

1 Arm Standing Cable Row

 

And lastly…

4. Overuse syndrome

44884_1519888129874_1614686679_1235711_3250555_n

Rest and recovery are probably the least planned and underutilized ways to enhance performance.

In 16 years of climbing and dealing with my own injuries, 3+ years of working with athletes’ broken bodies and 2 years of barbell training I have learned one thing:

YOU DO NOT GET STRONGER FROM YOUR TRAINING, YOU GET STRONGER FROM RECOVERING FROM YOUR TRAINING.

This is a hard fact for many athletes to face. We all want to push our bodies to the limit and we think that more is better. This really isn’t the case. I currently spend 5 days a week fixing athletes who train this way and spend a lot of time begging them to take some rest days.

If you don’t rest and recover your body won’t adapt to the stress of your training—you won’t get stronger. Neglect it for too long, and you will start to lose strength. You’ll sink into the black hole known as overtraining. First, your sleep patterns and energy levels will feel the effects. Eventually, your immune system crashes, and you lose your appetite. It’s like burning out your engine. Then you become at high risk for injury if you don’t have one already by that point. 

I wrote an entire post about this topic so to read more about it go HERE.

 

As I mentioned previously, there are many reasons why someone might have shoulder pain and that’s why it is important to seek professional help to get an accurate diagnosis.

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If you have any questions feel free to comment below.

If you think you have shoulder impingement syndrome come see me now at Motus Clinic and we can get you diagnosed properly, start the rehab process and get you back to climbing fast!

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6 responses to “Shoulder Impingement Syndrome Part 2 – Treatment

  1. Hello, great posts on shoulder impingement. I´ve had problems with my shoulders at several occasions, usually starting in spring time after training indoors during winter and then adding a few more weekly sessions to my training for the sesong coming up. Been to physiotherapist and doing the recomended exercises and resting it has disapeared after a month or so. But not this time… Started training crossfit 1 1/2 year ago and it felt really good up until about 1/2 a year ago. Thought i had a solution to my shoulder issues, doing more antagonist training But right before christmas i started to feel some pain in my shoulders again, after doing deep lockoffs on the campus. Stopped doing crossfit, and resting for a while from climbing it got better but not good. This time i also went to the doctor and got a MRI, which showed nothing wrong with my shoulders. Also got a ordinary x-ray which didn´t show anything wrong either. Got one cortisone injection in the bursa, right shoulder, doctor troubleshoting, but no difference. Got another cortisone injection beginning of mars in long head biceps tendon, both shoulder, felt like he struck exactly in the right spot according to where the pain is. Became better after a week or so and started climbing a bit harder again. But after a few weeks it got worse again. Now only climbed like 5 times since start of April and every time it feels alot worse the day after. Done some crossfit, which doesn´t make it worse as long as i avoid overhead pulling exercises. Also doing the exercises you recommend but i guess i could do them a bit more. Now it has been 2 months with almost no climbing so definetly time to cantact my doctor again. Pretty sure it´s the longhead of biceps tendon, distinct pain in spot in the front of the shouder, dull pain in biceps, and also the cortisone injection in biseps tendon helped temporarily. Don´t know what to do and not so eager for more cortisone. Would be interesting to hear what you have to say about this and also if you have any experience from similar problems among patients. Best regards //Peter

    • Peter, sorry to hear about all the shoulder troubles. If the cortisone worked on the biceps long head it sounds like you found the exact tissue that is troubling you. However, the reason that the cortisone shot gave you only temporary relief is because that painful biceps long head tendon is really just the victim of a larger problem with your shoulders. Your problem is not the biceps pain, that is just a symptom. The problem is somewhere else in the kinetic chain. It’s hard to say what the exact problem is with out getting my hands on your shoulder to see what your tissue quality is like and without seeing your posture and watching how your shoulders move. The exercises in this article are just a few suggestions and I don’t always use these exact exercises with everyone because everyone’s problems are slightly different. You may need to be doing something slightly different. My suggestions would be to try the following:

      1. Find a practitioner in your area who does Active Release Technique (ART) or deep tissue sports massage and get to work on the biceps, upper trap, pecs, lats and subscap. If you absolutely can’t find one then check out my article on Self Myofascial Release on this blog. I use this soft tissue technique on my patients because it works really well for stuff like this. I have had it done to me with great success for biceps and brachialis tendinitis.

      2. Find a good Physical Therapist or sports chiropractor who can assess your posture and your muscles and give you a customized rehab exercise plan. One size does not fit all. It really depends on your posture, alignment, specific muscle strengths and weaknesses and movement patterns.

      3. Change the way you climb. There is likely some flaw in your climbing technique causing this issue. If you have bad foot work or poor core control you will overuse your upper body and shoulder muscles which will contribute to the issue. Consider hiring a climbing coach for a period to refine your technique and movement. System training is an effective training tool in this regard.

      https://joshuatreebouldering.wordpress.com/2014/09/06/system-training-part-1/

      I hope that helps some. I wouldn’t suggest going for another cortisone shot. Those shots can weaken the tissue and cause problems later on if you get too many of them. Think tendon rupture here. I’ve seen it.

      Let me know if I can help at all. If you tell me what city you live in I may know someone there that can help.

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  3. Pingback: Shoulder Impingement Syndrome Part 1 | Natasha Barnes Climbing & Performance Therapy·

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