[miso soup]

I think I've got this.  Dull ache coupled with all sorts of clicking and clacking when I stretch my arms up and back.  A search on here brings up one thread where GCW says he doesn't like the term, care to expand?  A web search brings up a fair bit of stuff, some of it climbing specific.  I've stopped climbing and started caning Ibuprofen.  Yoga seems like it might help, my question is should I be doing rotator cuff strengthening exercises now or should I wait until it's better then start doing them so it doesn't happen again?

[ducko]

Unless it's really painful I'd start shoulder rehab I think most climbers get a twang in the shoulders alot usually due to imbalances, theres plenty on YouTube about imbalances if it gets bad see a physio as people can never accurately determine what's wrong with you over the net!

[ShortRound]

I recently saw a physio about my shoulder and describing it over the phone he assumed it'd be an impingement but on closer inspection it was a tight and knotted Rhomboid. It cleared up with some deep massage. I'd started doing theraband shoulder stability excercises before seeing him but was making it worse (by not getting the form perfect).

So, my advice would be to see a decent physio rather than just starting rehab stuff as it could be anything. I imagine asking on here for good shoulder or sports injury specialists in your area would find you someone decent. 

[GCW]

A search on here brings up one thread where GCW says he doesn't like the term, care to expand? 

Have you a link?

[miso soup]

http://ukbouldering.com/board/index.php/topic,14012.msg253209.html#msg253209

Thanks people.

I've already seen two physios, both of whom were fairly useless.  I've got the number of a climbing physio but any recommendations for people in London would be gratefully received.  I also saw a sports injury massage therapist who basically said 'I don't really know what's going on, you should probably see a physio' but then turned out to be more use than both the physios combined.  She reckoned there was more than one thing wrong with my shoulder, I think she might have managed to fix one thing which has revealed the full extent of the other.  It's not been right for over six months now, initially I couldn't stretch my arm up and back over my head.  After a lay off and the massage I got full range of movement back and discovered all the clicking and grinding when stretching into the positions I couldn't previously reach.  So there's now no significant pain and no restriction of movement, but it's definitely not right.  Dull ache, particularly after using it for anything, including rotator cuff exercises, and the racket when stretching it out.  The stuff I've been reading says if it gets bad it can require surgery (apparently Jerry had to have surgery because of it) so I'm a bit worried and very wary of making it worse.

[duncan]

Shoulder problems can be - very broadly - be categorised into two types: too much movement or too little movement.  Most of the typical non-traumatic climbers injuries - rotator cuff tears, SLAP (labral tear) lesions - are associated with excessive or non-ideal movement of the shoulder joint.  So GWC’s disliked term impingement is the mechanism; rotator cuff tear is the damage caused by the impingement.   

A slideshow here attempts to illustrate what I will attempted to describe.  Unfortunately google docs does not support animations so you are missing the humeral head moving superiorly, a typical cause of impingement.

The shoulder joint is a very shallow socket attached to the end of the shoulder blade with a ball perched uneasily in it [slide 2].  Think of a football sitting on a soup bowl.  If the ball does not remain centred in the socket as the arm moves the ball will pinch or 'impinge' [slide 6] and repeated impingement will hurt and eventually damage the structures around the joint.  The excessive movement can be tiny: the shoulder is tightly packed and only a little excess movement in the wrong direction can cause pain and / or damage.  A >2mm reduction of the subacromial space due to the humeral head translating vertically is thought to be pathological.   

What keeps the ball centred in the socket as the arm moves are well-coordinated muscles attached to the ball: the rotator cuff (an unfortunate name as the cuff muscles’ prime function has nothing to do with rotation) [slides 7-10].   At least as important as the cuff are the muscles that coordinate the movement of the shoulder blade (scapula).  If the socket is not pointing in the right direction in the first place all bets are off [slide 11-.12 = abnormal scapular motion; slide 13-15 normal scapular motion].  Slides 16-18 attempt to illustrate the importance of a flexible thoracic spine. 

Side 20 illustrates how strong/rapidly contracting upper and lower trapezius or serratus anterior can mitigate against impingement.  Slide 22 illustrates how tight/overactive rhomboids, pecs or levator scapulae can predispose to impingement. 

Any combination of any of the above in addition to rotator cuff weakness/poor timing could be part of the problem.  The underlying muscle dysfunctions can be quite varied, hence the difficulty of prescribing a simple set of exercises. 

Stretching the pecs, rhomboids and levator scapulae is rarely a bad idea; exercising the serratus and lower traps. is usually helpful.  Keeping your mid-back flexible is good.  I generally prefer to focus on these first before doing too much rotator cuff work.  Since the rotator cuff muscles don’t rotate, the typical theraband exercises which rotate the shoulder joint are probably not ideal. 

All or none of this may apply to the OP.  Usual guidelines regarding random advice on the internet apply.

[miso soup]

Brilliant, thanks for that.

The moral of the story is always ask UKB before giving hard-earned money to so-called professionals.

[GCW]

As nudcan (sic  ) says, my main beef with "shoulder impingement syndrome" is that it is a very vague term, that now seems to be becoming the norm for any shoulder gripes.  It isn't even specific as to where the impingement is going on.  I suspect a lot of the time, people are randomly labelling shoulder gripes with "SIS" rather than looking for, and treating, the specific problem.

I'd much rather someone came out and specified that there is supraspinatus pain +/- weakness, with or without impingement signs (all of which can be diagnosed fairly well by proper clinical examination).  At least then you know what to do about it.

There's various problems that can go on in the shoulder, so it's very important to assess it properly.  Not to mention other problems due to muscle instability outside of the shoulder, referred pain from the neck etc etc.  Go and see someone that knows what they are talking about.

[Johnny Brown]

I had exactly your symtoms a few years back. I went to a couple of physios who diagnosed various things but, despite initial confidence, were never able to offer more than temporary relief. In the end I took up yoga. It sorted out my posture and the muscle imbalances that were causing the problem. I don't really need to do it any more as my body is much more balanced, but it does help keep my back healthy.

[miso soup]

Stretching the pecs, rhomboids and levator scapulae... exercising the serratus and lower traps... Keeping mid-back flexible...

I'm going for all this plus yoga and Ibuprofen, crossing my fingers and keeping the climbing physio's number handy.

Again, many thanks.

[psychomansam]

Thanks duncan for the knowledge there. My right shoulder has been stalling my climbing for over a year. Can barely boulder at all as a result. Seen a physio, who was fairly unsure, and been lazy on the exercises, partly due to skepticism! Currently (re-)beginning yoga, getting a sports massage friend to attack the upper back behind it a bit. I'm busy and doing other things so been too lazy to sort it, but hopefully yoga will start stabilizing.

OP, just remember to get back into things gently. easy easy circuits, lots of varied movement etc. Routes are prob better than problems for taking it easy / self control with not pushing it too hard.

And since you want your body to recover I'll presume you're eating a healthy diet, no alcohol and plenty of sleep yes? 

[miso soup]

Healthy diet, no alcohol and plenty of sleep is pretty much business as usual for me.  I've actually been drinking slightly more than normal since I've been using all the non-climbing time to catch up with friends, but I can't see a few gin and tonics every week or two doing much damage to my shoulder.  Work does screw my sleep up sometimes but it's been alright recently. 

I have been trying to take it easy but it is difficult.  Easy bouldering almost seems like a contradiction in terms and getting on routes involves significantly more hassle for me.  But now I'm not climbing at all so when I do start again I'll no doubt have no choice but to climb a few grades below normal.

[duncan]

There was a clinical trial in the BMJ recently into specific exercise for shoulder impingement syndrome.  Some physios. will grumble about the one-size-fits-all exercises given, the specific exercise group did well and were less likely to need surgery.

Exercises the physiotherapists used.  Similar to those recommended above. 

Slightly pissed as it is the precise trial design I am piloting this summer!

[fatdoc]

Duncan and GCW on the money.

I agree with yoga, 10 years of chronic back pain is now a distant memory.

I do  nit have much more range in my... Very battered... Shoulders, but much better alignment.

Scap winging is easily sorted with the right tharaband exercises, u really need to see a physio that can help IMO.

[Huffy]

Some good input from (i'm assuming) qualified people.

I think its also worth remembering that impingement can be primary (i.e. more non-contractile reduced sub acromial space) and secondary (more contractile and dynamic dysfunction in scapulo-humeral rhythm).

Basically impossible to give any specific advice to people online though - go see a physio with good feedback and have them assess you properly.

[miso soup]

So maybe I should be doing rotator cuff exercises?  Having clicked some links on the BMJ site I'm now also concerned that my rice intake might be putting me at risk of diabetes.

The search for a physio with a clue continues.  Turning into an expensive business.  Of the two I've already seen the one who seemed least useless was keen for me to go and see him every couple of days, at 50 quid a pop that's unfortunately a lifestyle a little beyond my means.

[fatdoc]

There's gotta be a upper limb / climber savvy physio in a city of 5 million.

If theres no one on here with the knowledge.... And the local walls don't know

Consider askin on UKC.

Yep, it may have its uses, with a huge membership might help?

U really don't need to worry about the rice BTW.

[miso soup]

 

[mrjonathanr]

Why don't you contact somewhere with lots of boulderers like the Arch and see if there's any personal recommendations for physios?

[fatdoc]

 

[miso soup]

I have got a couple of recommendations from folk at The Arch, I'll be trying one of them this week.

[TerryLines]

I've been treated by Esther Rodrigo at the Marble Arch branch of Physio in the City.
Currently for shoulder impingement, but previously for a few things from running. She seems to know her stuff and I'd recommend her. The cost is £45 a session. My only gripe is that she could have sent me for an mri sooner, but she was trying to see if I could avoid surgery. In fairness, I was trying to avoid surgery too....

[miso soup]

Nice one, have your first wad point for your first post and welcome to UKB.

[Rocksteady]

I'd recommend James Thompson at Six Physio Monument branch. He's not treated climbers before me but has very much engaged with the climbing literature, has a good analytical approach and is currently fixing my shoulder/postural problems pretty well, mainly focusing on getting my thoracic spine flexing normally, stretching my lats, and strengthening my traps as antagonists to lats.

[TheBokonist]

To be honest I never really understand why people want physios who are "climbing specific." I guess it either means the physio has some appreciation of the demands climbing places on the shoulders (which any decent physio should be able to work out), or the physio isn't going to suggest "activity modification" in order to cure the shoulder problem.

Anyway, I'm unsure about climbing specific physio's, but if you want the best clinical care available, who's well respected nationally, typically sees patients other physio's struggle with, and sees all kinds of professional sports-people, I'd recommend Jo Gibson, based in Liverpool & West Kirby. Well worth travelling for if you've had persistent difficulties, want to know what's going on or aren't getting anywhere with your shoulders.. Pm me if you want more info.

[miso soup]

I'm seeing a guy called Christiano who climbs at Westway.  Seems to know his stuff.  The verdict is that it's not Shoulder Impingement Syndrome.  The noise would be very worrying if it was coming from the shoulder but it's actually the shoulder blade colliding with a rib, which is seemingly not so bad.

[Fultonius]

My turn. 

My shoulder has been getting niggly. I was at the physio yesterday for no less than 4 things (ankle, both knees, shoulder) and he reckons very minor sub-acromial impingement. He basically said I "should" take 6-12 weeks off climbing and do all the usual theraband/stratching stuff.

So, my question to all is - has anyone successfully managed to continue climbing while rehabbing this?  I'm pretty good at managing injuries (I've not stopped climbing for more than a few weeks in the last 3 years despite numerous pulley/collateral ligament/tendon strains etc - I've been able to "manage" them while still climbing and they've all fully recovered.

Duncan - you mentioned that theraband rotator cuff exercises might not be the best for regaining control of the rotator cuff - can you point to some better exercises?

[Fiend]

Yes but it's made the impingment fairly chronic if mild. And my shoulder mobility is terrible.

Sleeping badly on it is generally worse than climbing for me.

I'm probably a pretty useless example, HTH.

[Rocksteady]

I have found that I can climb through shoulder issues, but steep bouldering (especially indoors) makes it worse.

Aerocap-type easyish volume on routes actually seems to help my shoulder though.

[duncan]

Fultonius, your physio. is the one who has assessed your shoulder so has the best idea of what is going on here.

My default option and my personal experience is that a minor impingement is better for being climbed on at a moderate level, much as rocksteady says. There may be particular reasons why your physio. is more conservative.

My issue with theraband exercises for rotator cuff is mainly theoretical, I'm not aware that anyone has tested the effectiveness of different exercises in the shoulder. Some exercise of the right muscle is probably a lot better than nothing at all. However rotator cuff theraband exercises are not much like climbing, they are open-chain, dynamic, low load and often with the arm by the side. Given that climbing involves static contractions (or small movements at most) of the rotator cuff, closed-chain, heavy load and usually with the arm in the air, that's what you should try to emphasise.

This is from an earlier post, it's relevant for someone who, like me, gets pain typically in a high Gaston position:

I do a range of scapular stabiliser and rotator cuff style exercises. Most physios. will prescribe these and I have tried variations on them for decades but there have been two key changes that have helped me climb and train harder in the last 3-4 years.

The first one was focusing much more on the scapula stabilisers. I do lots of side and front planks and dynamic versions of these exercises: side-to-side push-ups, single-arm push-up, push-up into side-plank. These need to be done with excellent form. I think you need someone who knows what they are doing to teach you and correct any movement faults. If I was younger and stronger I would do handstands and handstand push-ups. I’m not, so I do supported hand-stand push-ups http://manbicep.files.wordpress.com/2013/06/handstand.png
  or push-ups in a ‘downward dog’ position.

The second key change was making exercises much more specific to the aggravating position and movement. The classical theraband rotator cuff exercises with the elbow on the hip are more or less ineffective for me. Arm by the side is nowhere near the difficult position for my shoulder and rotator cuff muscles don’t rotate the shoulder, they stabilise it. I now do lots of overhead work - close to or in the aggravating position - using the theraband to do resisted ‘gaston’ type movements. I do military presses with dumbells, with lots of variations in shoulder position.

I've recently added horizontal pull-ups (from a bar with feet on a chair or using rings with feet on the floor).

[TMR]

I would repeat what was written above; only your physio can correctly diagnose postural imbalance and specific issues ( especially in the shoulder which is a very complex joint!). I have however, had great results with self treatment of shoulder issues (following diagnosis from a physio!)

Read this:  http://www.exrx.net/Kinesiology/Posture.html

then this: https://www.t-nation.com/training/cracking-the-rotator-cuff-conundrum

then watch these: https://www.youtube.com/channel/UCob_Fn1Qyjf9-RRNfle_T7w

My issues were;

shortened and tight pecs, lats and biceps
weak and inactive rotator cuff muscles (external rotators)
lack of thoracic mobility
lordosis and scapular winging
poor climbing movement patterns
poor day to day posture.

They caused shoulder impingement and ulnar nerve compression. Over two years I have pretty much eliminated these issues with massage, stretching, exercises and an awareness of correct techinque and posture. I can give a full list of my shoulder routine if you like. Hope this helps!

[Fultonius]

My issues were;

shortened and tight pecs, lats and biceps
weak and inactive rotator cuff muscles (external rotators)
lack of thoracic mobility
lordosis and scapular winging
poor climbing movement patterns
poor day to day posture.

Sounds like me!

I can give a full list of my shoulder routine if you like. Hope this helps!

Yes please.

[TMR]

Here goes, i've done a lot of reading on this so i hope it doesn't turn into an incoherent stream of babble!

I split my shoulder exercises into two sessions to try and keep things simple. I perform the strength session 2/3 times weekly. Since my shoulder health feels good at the minute i'm only doing the mobility/conditioning session once a week.

Strength
I designed this session as something i can easily do at the end of climbing sessions. I get on the rings and perform dips followed by I's Y's and T's and face pulls. Form on these is crucial, look them up on youtube and be really strict with yourself otherwise you'll just end up causing more damage. Im committed to ALWAYS doing these after climbing. No excuses. I may soon start trying to increase the resistance on the IYTs and face pulls, but to be honest i'm still experimenting with the weight/rep structure as i've found conflicting advice on the web. I finish off with "push ups with a plus". For push up form i would recommend spending some time on the mobility wod website as the standard form most people use is pretty ropey.

Mobility/conditioning
This session takes longer, and as a result i only do it about once a week. I usually start with the exercise complex from the "Rotator Cuff conundrum" I linked to above. I follow this with the "drawsword" exercise from Joe Le Sage's videos focusing on shoulder and scapular position. Then i'll work through my pecs, lats, biceps and shoulder muscles with the foam roller and lacrosse balls for about half an hour. I would again recommend the Mobility wod website as there's too much info for me to put here. My focus tends to shift here depending on where feels particularly sore/tight.


It's worth noting it took me a while to get to this stage. My physio started with plenty of aggressive massage to improve tissue health coupled with stretching and some classic external rotator exercises with very light resistance to get everything moving properly. It's possible that some muscles have been so neglected that they don't fire at all, so getting them activated and building up the "mind-muscle" connection is an important first step. It's also worthwhile learning what good posture feels like! It took me a few months of concerted effort to stop slumping when i sat down and dropping my shoulder forward in it's socket on hard moves whilst climbing. All told i would say it's taken about 2 years to get to the point where my shoulders don't hold back my climbing.

[TMR]

Also, i would recommend buying Dave Macleod's injury book.

[Lund]

I had a panicked moment a few years ago where I had classic rotator cuff symptoms - pain raising the arm and sleeping.  So I immediately commenced resting until it stopped hurting at night and then did the usual theraband shit - outward rotations basically.  It didn't recur.

More recently - a year or more - I came to the realisation that actually it's more about balance - as duncan says in his posts, the shoulder joint is a shallow one with everything held just so by muscles.

So my personal advice is as with all these things - rest until you can do normal life without pain, then fix it.  To fix it, I think for a climber this means fuckloads of hard pressing.  Personally I like to work the planche progressions and do the floor based L-sit.  As a brucey bonus I have some impressive tricks to bust out near the yoga bunnies and the extra shoulder and compression power comes in handy every now and again.  Whatever you choose - remember that you can't just do 10 press ups after a session - that's too easy.  You need to balance out those batfink latwings, so that means work not warm up.  The work is proportional to the size of the muscle though, so don't go lifting 50kg on a lateral rotation rotator cuff exercise...

[Fultonius]

Very bizarrely, doing those T-Nation 4 minute workouts using the "push back-press-up" has apparently "cured" my shoulder. Since doing 2 set (and letting lat/serratus anterior?? DOMS) my shoulder has been pain free. Could weak lats serratus anterior be causing this?!? I know, strange for a climber but 

[Lund]

IMHO: seems unlikely with just doing that number of reps.  More likely a coincidence, and if not - the fact that the press-up element and the fact that your hands are behind your shoulders a bit (which works the front of your shoulder) will have loosened up some of the tight muscles in the shoulder joint.

Related to some of the previous posts btw - L-sit dips on rings is an antagonist exercise worthy of kings but might (depending on how hence one is) need working up to with support work/dips on bar/without the L-sit part.

[Sasquatch]

Very bizarrely, doing those T-Nation 4 minute workouts using the "push back-press-up" has apparently "cured" my shoulder. Since doing 2 set (and letting lat/serratus anterior?? DOMS) my shoulder has been pain free. Could weak lats serratus anterior be causing this?!? I know, strange for a climber but 

If so, it's more likely a stretching shoulder opening action rather than a "strength/weakness" issue, which seems to my uneducated mind to be in line with SIS.

[TMR]

the serratus (or Boxer's) muscles help control scapular winging (which increases the chance of impingement with arm elevation). Although to fix that in such a short time frame doesnt seem likely! 

[Fultonius]

Makes sense, the stretching thing.  Downward pointing dogs from now on then!

TBH my should issues have coincided with my using rings, which I've not done before - so maybe poor form, or just imbalance/weakness/tightness.

[paulwelford]

First and foremost - confirm the diagnosis by seeing a trusted professional.

Shoulder impingement Management:

Initial treatment:
When really severe/acute, much of the pain comes from the subacromial bursa (a physiological cushion) in your shoulder.
A corticosteroid injection under ultrasound guidance will help settle things well enough to engage in rehab. If you don't do the rehab, the pain will recur.

Rehab:
There are really several strands to this, all of which are essential.

1. Subject the supraspinatus tendon to regular, systematic and progressive loading (see a physio for this. If you're struggling to find a someone, you can see me).
2. correct surrounding, contributing factors eg capular mobility and scapular stability, as other people have mentioned.
3. progressive to correcting muscular asymmetry and imbalance in more distant structures, as these can cause you to overload the shoulder complex without you realising it.
4. Accept that impingement syndrome is a chronic, relapsing-remitting condition and will require you to keep on top of points 1-3 throughout you climbing career

You could also have a sub-acromial decompression, but the vast majority of patients don't require this.

I do specialise in this so feel free to visit me if you need help. I'm in SW London.

Also if you have time, please check out my anatomy survey, which I have posted on the forum today.

Good luck and happy climbing

[Fultonius]

First and foremost - confirm the diagnosis by seeing a trusted professional.

Shoulder impingement Management:

Initial treatment:
When really severe/acute, much of the pain comes from the subacromial bursa (a physiological cushion) in your shoulder.
A corticosteroid injection under ultrasound guidance will help settle things well enough to engage in rehab. If you don't do the rehab, the pain will recur.

Rehab:
There are really several strands to this, all of which are essential.

1. Subject the supraspinatus tendon to regular, systematic and progressive loading (see a physio for this. If you're struggling to find a someone, you can see me).
2. correct surrounding, contributing factors eg capular mobility and scapular stability, as other people have mentioned.
3. progressive to correcting muscular asymmetry and imbalance in more distant structures, as these can cause you to overload the shoulder complex without you realising it.
4. Accept that impingement syndrome is a chronic, relapsing-remitting condition and will require you to keep on top of points 1-3 throughout you climbing career

You could also have a sub-acromial decompression, but the vast majority of patients don't require this.

I do specialise in this so feel free to visit me if you need help. I'm in SW London.

Also if you have time, please check out my anatomy survey, which I have posted on the forum today.

Good luck and happy climbing

Some feedback for anyone with similar issues.

I found that this time theraband internal & external rotation (the standard "impingement" treatment) really wasn't working and, some days it seemed to aggravate it. Paul's advice of doing some supraspinatus exercises (I used these ones: ) seemed to make the most difference. It's feeling a lot better, barely notice it now.

Ibuprofen gel when it was feeling most tender also seemed to speed up recovery. [/anecdotal]

[ghisino]

currently having an episode in my right shoulder.

while checking its mobility and movement patterns in front of a mirror, two things strike me:

1) restricted arm adduction when the scapula is fixed (i can lift the left elbow a bit more without releasing the scapula)

2)when trying to do the above test, firing my superspinatus as best as i can, i feel some kind of tightness goind down my arm, roughly in between  triceps long head and bicep. This is more pronounced if i bend my elbow. Palpating the affected region i can feel a sort of cord...I have no clue what the hell it is.

any clues, especially concerning 2?

[kelvin]

 My physio started with plenty of aggressive massage to improve tissue health coupled with stretching and some classic external rotator exercises with very light resistance to get everything moving properly. It's possible that some muscles have been so neglected that they don't fire at all, so getting them activated and building up the "mind-muscle" connection is an important first step.

Which is basically where I am at the moment - whiplash from rolling the van back in April has shown up all manner of niggles and the physio, a lucky 'find' at a local hospital, has just started me on very basic strengthening with a theraband in order to re-activate muscles that ceased firing many years ago. All work related of course. Impingement of the bursa in the shoulder, no flexibility of the thoracic spine at all and basically the muscles used to initiate pullups have long been forgotten by my brain.
I was hoping to be headed back to Spain for the winter in October but she's very much of the opinion that it'll take a lot longer to get everything working as it should - so at the moment, it's lots of stretching (and yoga) and small lightly loaded movements to get this 'mind-muscle' thing happening. Yesterday, after a month of doing what I'm told, I can actually feel the muscles between my shoulder blades starting to respond 

It feels like it's going to be a slow journey but a good one. There's some great links above, so thanks everyone who's took the time to post. It's muchly appreciated and I'm hoping will make a big difference to my recovery.