Upper Extremity Calamity

I am fortunate in what I do to come across many great athletes, quite a few early in their careers.  Over the years the athletes’ training regimes have become more sophisticated and calculated, while the injuries, although fewer, have remained to some extent the same.  Throughout the next few paragraphs injury and dysfunction may be used interchangeably, since most injuries begin as dysfunction. That is not to downplay the severity of the presenting complaint, as many of the resulting injuries can become quite serious.

Let us begin with debatably the most common complaint before, during, or after weight lifting: shoulders.  “My shoulder hurts” or “my shoulder hurts when…” are the two most common phrases I hear coming from a gym setting.  That being said, most are related to activities and dysfunction outside the gym or by bad habits in the gym. Bad habits include but are not limited to incorrect weightlifting form, overworking the same muscles, and improper warm-up, which can be lumped in with too heavy, too fast.  

Those aside, others can be linked to the twenty-three hours outside the gym.  Let me use myself as an example. When not seeing patients I am sitting on a stool in front of a computer as I am now.  While this affects the entire body, look at the positioning of the upper body: chest and rib cage are lowered reducing the amount of space the diaphragm can utilize, excessive thoracic spine flexion, shoulders rounded forward, shoulder blades protracted, arms internally rotated and hands pronated, neck extended and chin protruding forward, all while the trapezius is engaged.  This visual can be applied to almost every non-traumatic shoulder complaint even if this doesn’t occur seated. Other ways this positioning can occur are from abdominal, chest, and bicep dominance, or the vanity portion of overworking the same muscles from earlier. To correct this most coaches understand to work posterior chain muscles, such as 1:2 or even 1:3 as far as chest to back sets.  Also we can work on mobility of the thoracic spine and shoulders, using foam rolling, PVC pipe, stretching, etc. I am not here to talk about things we already know, however.

Assuming we have a good understanding of the importance of warm-up, mobility work, and program design balance, we can move on to the rest of the conversation: the injuries.  I am not here to help self-diagnose, but for you to understand the biomechanics of these injuries in hopes of preventing them by applying this knowledge. Only a medical professional that is licensed can diagnose and treat these injuries, but again you can use this understanding of the injuries to help prevent or attenuate the issue until advice is sought out.

Shoulder impingement/tendinopathy

Pain during shoulder abduction that usually comes and goes around 90-110 degrees or pain during any part of the motion.  This usually stems from scapular dysfunction. The scapula moves out of the way as the arm is raised overhead and if this doesn’t occur properly there is resulting pain.  This usually is related to the supraspinatus tendon getting pinched under the acromion process of the scapula. If left unchecked this can become a repetitive irritation of the tendon, aka tendonitis.  So in reality one could argue they mean the same thing. Why does this happen? Many reasons that can be narrowed down upon examination. Increased tension of pec major, subscapularis, trapezius, or latissimus can all cause the humerus to incorrectly centrate in the shoulder joint and cause the impingement described.  The key is joint centration by balancing shoulder muscles and fixing scapular dysfunction, usually by increasing the tone of opposing muscles and releasing the tightened muscles.  

This can also be the result of an impeded diaphragm.  This in itself would take an entire lecture to discuss but can be summed up by never sucking in the stomach and learning to brace and breath with the entire core while movement occurs.  Most of us are chest breathers, which plays a huge part in shoulder biomechanics.

Rotator cuff tear

The cause of this can be either traumatic or degenerative, but the good news is 25% of people have rotator cuff tears over the age of 50, and 50% have tears over the age of 70.  Did I mention that these are asymptomatic also! So even tears can heal, but the problem lies in the scar formation and the type and severity of the tear. That is why many who have tears don’t require MRI unless they fail a course of rehabilitation or have severe symptoms.

Rotator cuff sprain/strain

Sprain/strain could be classified as overuse or even a traumatic painful episode after lifting which did not cause a tear.  The majority of shoulder cases after a traumatic event are these. Many begin with improper scapular biomechanics, or after the scapula and shoulder are forced to do something it is not ready or willing to do, usually compensating for lack of motion elsewhere in the kinetic chain.

Sensation disturbance in arm or forearm (numbness, tingling, or pain)

This could possibly be the most serious issue listed.  There are a host of issues that could be going on but most are related to repetitive use and can be relieved with proper treatment and corrective/ therapeutic exercises.  Most common are radiating pain from adhesions in between shoulder blades, radiating neck pain, radiating shoulder pain, and sensation disturbance due to tight or fibrotic muscles.  After a thorough examination many of these cases can be resolved with proper treatment including A.R.T, manual therapy, therapeutic exercise, and altering ergonomics, while some also may need co-management with physiatrists or orthopedists.

Reduced ROM overhead

The most common request is for increased ROM overhead.  The most important issue here would be diagnosing where the dysfunction is coming from.  Decreased thoracic extension, scapular dysfunction, glenohumeral joint or capsular adhesion, paradoxical breathing, core control, and even hip flexibility depending on location of the body when pressing overhead.  While many of these issues can be cleaned up with proper warm-up and mobility work, sometimes other issues are overlooked and unhealthy compensations can occur, which may lead to symptoms down the road.

Shoulder Instability

Another piece of the shoulder complex is the question of too much mobility.  While not enough can cause problems the opposite is also true. In some instances shoulder pain can be from too much motion in the shoulder joint, which also disrupts joint centration and can damage the joint itself.  The key is training key muscles surrounding the head of the humerus in the joint to maintain its position during movement. There are simple tests to determine if this is true, but leave them unchecked and pain could persist or get worse.

The takeaway message is simple: learn proper movement and technique first, properly warm-up, give adequate attention to deficits in mobility, have multiple trained professionals give opinions on tissues blamed for lack of mobility, and if all else fails have a health professional take a look, since many of these issues plague us all and can be corrected with proper treatment and attention.

Train smart.

Brian Watters, D.C., L.Ac., M.S., CSCS