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New 'Physio Clinic' Q&A session (Read 173655 times)

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#325 Re: New 'Physio Clinic' Q&A session
October 10, 2014, 01:51:24 pm
Hello HP Clinic.

I have a recently acquired problem I was hoping you could possibly advise me on. I have started with some discomfort in my left elbow. I've never had any trouble with it before. I've had a niggling pain in it, certainly worse when my arm is fully bent. I do a physical job which isn't helping but being self employed, no one pays you for being off ill though. Climbing wise it's been slowing me down, and tonight it reduced me to a stop. I just couldn't put any power through my arm at all and started peeling off problems, even easy stuff. The sore area is just up from my actual elbow joint, a few inches up my forearm. Sorry about the lack of specifics, quite hard to describe. Tonight it has also left me with pins and needles in my forearm and the back of my hand, which is a first. My training sensei has advised I treat it with ice and heat, and anti inflammatory if needed. Any other input at all? I have my first trip to font at the end of the month, so no pressure  :'(
Hi, the first thing that springs to mind when you describe pins and needles is that you have irritated or compressed a nerve around the elbow.
The median nerve (http://en.wikipedia.org/wiki/Median_nerve#mediaviewer/File:Nerves_of_the_left_upper_extremity.gif) runs through the front of the elbow and the radial nerve slightly to the outside. If you have been doing a lot of locking out and fully bending your elbow then you might have compressed them a little more than they would like.
I would recommend that you stay away from any locking out manoeuvres or too much elbow bending with strong biceps contraction. Try this nerve mobilisation technique from this link
Let me know how things are going and if it is not settling see a physio.
regards
Matt

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#326 Re: New 'Physio Clinic' Q&A session
October 10, 2014, 02:02:27 pm
Hi there Steve and gang,

Hoping you can help me out; as you have done in the past...

Whilst climbing on Tuesday I was doing a move where was hanging by my arms and trying to lift my feet up to a foot hold very high up and to my left. So I basically doing an awkward knee lift and twist, which I must admit didn't feel plausible, but I was just trying to stay on the route!

My attempt ended with a sharp pain on the right side of the front of my torso at the bottom of my ribs and was accompanied by snappy noise.

The pain now comes when moving around in bed, looking over left shoulder (reversing!) and various other things where I engage my right hand side upper body. As I write this I am less than 48hrs in so might be jumping the gun a bit as I imagine that a period of healing might just sort it out. But because of that unpleasant noise at the point of the injury I thought I would try to get some understanding of what I might have done to myself!

Any ideas?

Many thanks for any help.

Richard W
Hi Richard,
It sounds like it could be muscular. The click or pop could have come from a joint either from the thoracic spine or lower rib area. Sometimes if the force is at an end range of movement ie extreme stretch, then a joint will release a bubble of CO2 and you will here a pop. We will sometimes get a similar sound if we administer a controlled manipulation.
I don't feel it is anything to worry about and you are right it is still very acute. Keep gently moving your neck and trunk as symptoms allow and ease off the grades. Slowly increase the grades as symptoms allow.
Let me know how your are going next week.
regards Matt

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#327 Re: New 'Physio Clinic' Q&A session
October 10, 2014, 03:40:08 pm
Matt,
Thanks for the help, I'll see how it improves in the next few days.
Richard.

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#328 Re: New 'Physio Clinic' Q&A session
October 24, 2014, 10:32:13 am
Hi

I have a problem with my right shoulder but this particular problem has effected both shoulders at different points in my life.

When I raise my arm it feels like its ROM gets restricted as I'm approaching shoulder height and it becomes uncomfortable as I get above shoulder height. I have very pronounced Acroniums and I wonder if it's causing some sort of obstruction when I raise my arm. I can feel a bit of crunching around that area when trying to do exercises that require raising my and and when I am lowering from a one-arm pull up, I can feel a bit of crunching on the way down at the last stage of lowering, perhaps the last inch or two.

I have a feeling that some of the problem is that I'm not putting my joint into a great position sometimes when climbing (not pulling my shoulders back and down?). I don't really do any antagonistic work on my shoulders and seeing as I climb so much I'm sure that proper shoulder position and antagonistic stuff would help with this?

I'd appreciate any advice you can give and most likely, I'd come in for you guys to take a look. Who would be the best person to see regarding shoudlers?

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#329 Re: New 'Physio Clinic' Q&A session
October 24, 2014, 12:54:25 pm
Matt,
Thanks for the help, I'll see how it improves in the next few days.
Richard.
Update: Well my coughing breathing moving in bed is no longer a problem. Just getting a bit of pain if engage my abs with some certain movements. a regular sit up is ok and it wasn't 2 weeks ago. Although the hypochondriac in me would like an exact diagnosis, I think I may be better to continue staying as active as I can be whilst avoiding anything that causes the pain. then hopefully a few more weeks might see it right. Does this sound like the best way forward?
Cheers,
Richard

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#330 Re: New 'Physio Clinic' Q&A session
November 01, 2014, 02:56:05 pm
Two Fridays with no reply, I take it that this thread has fizzled out now?

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#331 Re: New 'Physio Clinic' Q&A session
November 07, 2014, 02:19:52 pm
Hi

I have a problem with my right shoulder but this particular problem has effected both shoulders at different points in my life.

When I raise my arm it feels like its ROM gets restricted as I'm approaching shoulder height and it becomes uncomfortable as I get above shoulder height. I have very pronounced Acroniums and I wonder if it's causing some sort of obstruction when I raise my arm. I can feel a bit of crunching around that area when trying to do exercises that require raising my and and when I am lowering from a one-arm pull up, I can feel a bit of crunching on the way down at the last stage of lowering, perhaps the last inch or two.

I have a feeling that some of the problem is that I'm not putting my joint into a great position sometimes when climbing (not pulling my shoulders back and down?). I don't really do any antagonistic work on my shoulders and seeing as I climb so much I'm sure that proper shoulder position and antagonistic stuff would help with this?

I'd appreciate any advice you can give and most likely, I'd come in for you guys to take a look. Who would be the best person to see regarding shoudlers?
Hi, sorry about the delay in responding, I have been on hols plus illness.
It sounds like you are impinging ie getting increased pinching/ compression of the rotator cuff muscles (small muscles that are the foundation of all your shoulder movements - they basically keep your shoulders stable). This problem often occurs around the shoulder height position.
You may be tight in your side trunk muscles and this will pull down on your shoulders and put them at a mechanical disadvantage. Your thoracic spine (mid) is important for shoulder movements and this may also be stiff.
Don't necessarily pull your shoulders down and back as this may increase symptoms. The shoulder girdle position needs to be looked at but in conjunction with the rest of your body.
I think it would be best to either book in with myself or Steve at the clinic as I don't think we can fully understand your problem until we look at you.
kind regards Matt

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#332 Re: New 'Physio Clinic' Q&A session
November 07, 2014, 02:22:33 pm
Matt,
Thanks for the help, I'll see how it improves in the next few days.
Richard.
Update: Well my coughing breathing moving in bed is no longer a problem. Just getting a bit of pain if engage my abs with some certain movements. a regular sit up is ok and it wasn't 2 weeks ago. Although the hypochondriac in me would like an exact diagnosis, I think I may be better to continue staying as active as I can be whilst avoiding anything that causes the pain. then hopefully a few more weeks might see it right. Does this sound like the best way forward?
Cheers,
Richard
Hi that sounds like the best way. keep increasing the volume and intensity of the climbing as symptoms allow.
Regards Matt, sorry about the delay in responding

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#333 Re: New 'Physio Clinic' Q&A session
November 07, 2014, 04:48:38 pm
Hi

Ok my problem/pain is in my right bicep. I can make it hurt by contracting bicep with my palm facing out. The pain is near the elbow end of the bicep. Its been like this a while, about month and half. I train or boulder lets say an average of 4/5 days a week, maybe pushing it a bit recently. I actually have a similar pain in the left bicep as well, but less so.

cheers in advance
Hi, it is difficult to say whether you have a purely biceps problem as it could also be deeper ie elbow joint. It hurts when you have your palm facing outwards which is actually taking load off the biceps (the biceps flexes and rotates the lower arm from palm down to up). It could be that you are compressing the joint ie fully flexed elbow and a biceps contraction.
As both biceps are hurting it is probably more due to the recent increase in intensity. I would tend to think that you need to back off on the intensity and climb at a pain free level and then slowly increase the loads/grade as symptoms allow. Maybe stay away from locking out on the elbows for the next few week. When you are back to climbing fully again just make sure you monitor the intense sessions and ensure you have easier sessions on following days particularly when you are climbing frequently.
Other possibilities are that sometimes the neck or upper back can refer pain and we would tend to assess what your shoulder and trunk is doing and are you pulling too much through your elbows. Hope this helps and let me know if symptoms persist, regards
Matt

Hi Mat

Thanks for your reply. I just gave myself a little test. The right bicep is quite a bit worse and hurts if I do a regular bicep curl, as well as the palms out indicator I gave you. It doesn't hurt deadhanging. Thinking back I did do quite a lot of deep lock training on rings and campus boards about two/three months ago. Since then I have been focusing on projects which are generally steep and fingery and haven't caused much pain. The pain got worse three days ago after a session on a problem that again involved a deep lock on a big hold.

I did some research and thought maybe distal bicep tendonitis.

I've also been climbing a very long time, ie I'm old! so maybe posture is a key as well.

cheers Andy
Hi Andy, you may have overloaded the distal tendon but it is less likely to be a tendonitis ie inflammatory as it has been going on for a 2 month period. It could be more of a tendonosis ie more wear and and tear, but only a problem if the tendon is overloaded to soon or too much. It is difficult for an exact diagnosis when it is deep elbow pain. The action you describe is both when the biceps is contracting and the joint is being compressed (also some of the nerves around the elbow can be compressed).
Poor posture can certainly contribute and often climbers are stiff in their mid back region. This area is important for reaching and stretching your arms out for holds. If you are in a sedentary sitting job then make sure you move regularly and do neck and trunk rotations and lift your chest and occasionally reach towards the ceiling.
As before avoid extensive locking out positions and reduce your load and grades. Increase as able and maybe you need to come in or visit a physio.
regards
Matt

Hi Matt

Slightly worrying how long ago my original post was! I still have a deep bicep pain, worse in my right bicep. Hurts now in some everyday situations, such as carrying a laptop with bent arm, and when I wake up, a good stretch helps. pain is no worse when climbing and doesn't limit a session at all. Getting a bit fed up with it now. Any ideas? cheers Andy

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#334 Re: New 'Physio Clinic' Q&A session
November 10, 2014, 09:16:41 am
How long does it take for tennis elbow to improve? Mine has been giving me problems for a few months now. I had it diagonsed first by a GP, confirmed by a physion, and have been doing eccentric curls as recommended by Dave MacLeod, Julian Saunders etc, and there's not been much sign of improvement. I've barely climbed at all since I did it.

Thanks

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#335 Re: New 'Physio Clinic' Q&A session
November 10, 2014, 06:35:40 pm
Sorry this is a post from my partner (who isnt on ukb), not me:

Hello. I am on a long climbing trip at the moment and my right elbow has been really sore for about 2 months. It is painful on the bone on the thumb side but also some pain up the back of my arm. I also have a neck problem which I have had for a few years and I guess might be connected. I have pain in the muscle that runs from the neck to the shoulder and sometimes this makes my upper back really tight where it meets the spine. I can reduce this issue by massaging the pressure point (??) on my neck to remove the tightness across my back, which leaves a sore lump on the pressure point in my neck. Any suggestions for stretches/remedial action that might be useful? I seem to notice more pain in my elbow when I use flat rarther than in cut holds. I get pain when I use my fingers - e.g. picking up a bottle. The elbow is the main problem currently but any suggestions for either if you feel the neck and shoulder issues are not connected would be great.

Many thanks,
Caryl

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#336 Re: New 'Physio Clinic' Q&A session
November 14, 2014, 12:14:55 pm
Hi

Ok my problem/pain is in my right bicep. I can make it hurt by contracting bicep with my palm facing out. The pain is near the elbow end of the bicep. Its been like this a while, about month and half. I train or boulder lets say an average of 4/5 days a week, maybe pushing it a bit recently. I actually have a similar pain in the left bicep as well, but less so.

cheers in advance
Hi, it is difficult to say whether you have a purely biceps problem as it could also be deeper ie elbow joint. It hurts when you have your palm facing outwards which is actually taking load off the biceps (the biceps flexes and rotates the lower arm from palm down to up). It could be that you are compressing the joint ie fully flexed elbow and a biceps contraction.
As both biceps are hurting it is probably more due to the recent increase in intensity. I would tend to think that you need to back off on the intensity and climb at a pain free level and then slowly increase the loads/grade as symptoms allow. Maybe stay away from locking out on the elbows for the next few week. When you are back to climbing fully again just make sure you monitor the intense sessions and ensure you have easier sessions on following days particularly when you are climbing frequently.
Other possibilities are that sometimes the neck or upper back can refer pain and we would tend to assess what your shoulder and trunk is doing and are you pulling too much through your elbows. Hope this helps and let me know if symptoms persist, regards
Matt

Hi Mat

Thanks for your reply. I just gave myself a little test. The right bicep is quite a bit worse and hurts if I do a regular bicep curl, as well as the palms out indicator I gave you. It doesn't hurt deadhanging. Thinking back I did do quite a lot of deep lock training on rings and campus boards about two/three months ago. Since then I have been focusing on projects which are generally steep and fingery and haven't caused much pain. The pain got worse three days ago after a session on a problem that again involved a deep lock on a big hold.

I did some research and thought maybe distal bicep tendonitis.

I've also been climbing a very long time, ie I'm old! so maybe posture is a key as well.

cheers Andy
Hi Andy, you may have overloaded the distal tendon but it is less likely to be a tendonitis ie inflammatory as it has been going on for a 2 month period. It could be more of a tendonosis ie more wear and and tear, but only a problem if the tendon is overloaded to soon or too much. It is difficult for an exact diagnosis when it is deep elbow pain. The action you describe is both when the biceps is contracting and the joint is being compressed (also some of the nerves around the elbow can be compressed).
Poor posture can certainly contribute and often climbers are stiff in their mid back region. This area is important for reaching and stretching your arms out for holds. If you are in a sedentary sitting job then make sure you move regularly and do neck and trunk rotations and lift your chest and occasionally reach towards the ceiling.
As before avoid extensive locking out positions and reduce your load and grades. Increase as able and maybe you need to come in or visit a physio.
regards
Matt

Hi Matt

Slightly worrying how long ago my original post was! I still have a deep bicep pain, worse in my right bicep. Hurts now in some everyday situations, such as carrying a laptop with bent arm, and when I wake up, a good stretch helps. pain is no worse when climbing and doesn't limit a session at all. Getting a bit fed up with it now. Any ideas? cheers Andy
Hi Andy, I am sorry to hear your are still experiencing problems. I think it would be best to book an appointment with a physio to get a full assessment. If you are local to Sheffield either book in with myself or Steve Hodgson.
regards
Matt

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#337 Re: New 'Physio Clinic' Q&A session
November 14, 2014, 12:20:40 pm
Hi there,
I've a sharp pain (almost spasm) in my lower left back moving down the top of the back of my left buttock (if that makes sense). Hard/impossible to put socks on first thing, but eases off after I've been up and moving for a bit. I'm wondering if its lower back (where I've had problems before) or something to do with my leg/bum/hamstring area? It came on after (a few hours after) trying some high leg compression moves...
Doing some basic stretches - and single leg raises (esp left) seem to twinge it....
Tom

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#338 Re: New 'Physio Clinic' Q&A session
November 14, 2014, 12:35:13 pm
Sorry this is a post from my partner (who isnt on ukb), not me:

Hello. I am on a long climbing trip at the moment and my right elbow has been really sore for about 2 months. It is painful on the bone on the thumb side but also some pain up the back of my arm. I also have a neck problem which I have had for a few years and I guess might be connected. I have pain in the muscle that runs from the neck to the shoulder and sometimes this makes my upper back really tight where it meets the spine. I can reduce this issue by massaging the pressure point (??) on my neck to remove the tightness across my back, which leaves a sore lump on the pressure point in my neck. Any suggestions for stretches/remedial action that might be useful? I seem to notice more pain in my elbow when I use flat rarther than in cut holds. I get pain when I use my fingers - e.g. picking up a bottle. The elbow is the main problem currently but any suggestions for either if you feel the neck and shoulder issues are not connected would be great.

Many thanks,
Caryl
Hi Caryl, read the previous response to the post on elbow pain. I would certainly look at your neck to begin with as the cervical spine can definitely refer pain into the elbow and further down your arm. As you have had this problem for a couple of months you may also be compensating due to the elbow pain and causing increased tension around the neck (get someone to look at whether you are doing odd movements with your arm etc). Make sure you have full neck rotation and that you have full trunk rotation in sitting. If it is possible you need to back off on the intensity of the climbs and try and climb with minimal symptoms. If it is possible it may be worth getting an elbow support or if you are away from civilisation then try and tape just below they sore spot on your elbow. You can attach the tape to the extensor muscle group and pull either way. Try it one way and see how picking up a bottle is. If it doesn't help pull the tape the other way. Be careful not to go right around the arm or too tight. Let me know how you are going and perhaps catch up with a physio on your return.
regards
Matt

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#339 Re: New 'Physio Clinic' Q&A session
November 14, 2014, 12:45:12 pm
Hi there,
I've a sharp pain (almost spasm) in my lower left back moving down the top of the back of my left buttock (if that makes sense). Hard/impossible to put socks on first thing, but eases off after I've been up and moving for a bit. I'm wondering if its lower back (where I've had problems before) or something to do with my leg/bum/hamstring area? It came on after (a few hours after) trying some high leg compression moves...
Doing some basic stretches - and single leg raises (esp left) seem to twinge it....
Tom
Hi Tom, it sounds like you have irritated your lower back and getting a bit of referred pain into your left buttock. This will usually settle down within 2 weeks particularly as you only have local pain ie not going down in to your leg. The morning stiffness is quite characteristic of acute lower back pain particularly as you have been still for 7-8 hours. As long as you feel better for moving then continue to increase your walking and do some basic lower back exercises ie knees to chest, trunk rotations and some pelvic tilts.
The first 2-3 days can be painful but then you should improve and start to move better. The sooner you can relax and bend forward without guarding or spasms the better things will be. Perhaps lay off the climbing until you can move with minimal stiffness but kee active ie don't sit around. Let me know how you are going and if things aren't progressing give us a call. Sometimes we need to assess why you have had lower back pain particularly if it is reoccuring
regards
Matt

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#340 Re: New 'Physio Clinic' Q&A session
November 14, 2014, 12:51:14 pm
Thanks Matt - off to a wedding tonight, so I now have the perfect excuse not to dance then! :D

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#341 Re: New 'Physio Clinic' Q&A session
November 14, 2014, 12:53:18 pm
I am on a long climbing trip at the moment

I think Caryl's injury has been brought on by her partner's excess smugness/relentless amazing venue photo posting...

HP guys - I rolled my ankle last week and was wondering what sort of rehabilitation exercises I should be doing? Cheers!

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#342 Re: New 'Physio Clinic' Q&A session
November 19, 2014, 06:48:18 pm

Thanks Matt - off to a wedding tonight, so I now have the perfect excuse not to dance then! :D

Went to see a physio in Manc on Monday - and it seems I have a strained/pulled glute.. Still painful..

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#343 Re: New 'Physio Clinic' Q&A session
November 20, 2014, 07:49:07 am
How long does it take for tennis elbow to improve? Mine has been giving me problems for a few months now. I had it diagonsed first by a GP, confirmed by a physion, and have been doing eccentric curls as recommended by Dave MacLeod, Julian Saunders etc, and there's not been much sign of improvement. I've barely climbed at all since I did it.

Thanks

Was this one overlooked?

Thanks Again

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#344 Re: New 'Physio Clinic' Q&A session
November 20, 2014, 03:46:56 pm
Matt,

Thanks for the reply, much appreciated. We are back in the uk for a few weeks soon so I will definitely see a physio. Good suggestions re taping and support too. Will investigate.

Caryl via Benf

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#345 Re: New 'Physio Clinic' Q&A session
November 21, 2014, 03:57:06 pm
How long does it take for tennis elbow to improve? Mine has been giving me problems for a few months now. I had it diagonsed first by a GP, confirmed by a physion, and have been doing eccentric curls as recommended by Dave MacLeod, Julian Saunders etc, and there's not been much sign of improvement. I've barely climbed at all since I did it.

Thanks
.

Was this one overlooked?

Thanks Again
Hi sorry I must have overlooked your email.
This would probably suggest that your initial diagnosis is probably incorrect. Unfortunately Tennis elbow is often used for any elbow pain. Eccentric exercises don't always help and the evidence on whether they work for the upper limbs is debatable.
The elbow joint can refer pain and there are also nerves that pass through or near to the elbow. These can become compressed or over stretched. I would also look at what your shoulder and trunk are doing as weakness or loss of control around these areas will mean more stress through your elbow. I would also want to clear your neck as this can also refer into your elbow area.
If you are local then perhaps I would come in for an assessment or get another opinion.
regards
Matt

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#346 Re: New 'Physio Clinic' Q&A session
November 21, 2014, 04:00:24 pm

Thanks Matt - off to a wedding tonight, so I now have the perfect excuse not to dance then! :D

Went to see a physio in Manc on Monday - and it seems I have a strained/pulled glute.. Still painful..
Hi, sorry to be devils advocate but I have never seen anyone with a gluts strain in 17 years! get your back checked out soon.
regards
Matt

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#347 Re: New 'Physio Clinic' Q&A session
November 21, 2014, 05:23:13 pm
Hi Matt - was having another session when you replied...

She worked my lower back and also hamstring a lot... But spent 15 min hammering my glute (deep) and you could feel it free up...

A week on it feels like someone is twisting a knife deep in my arse/buttock above the hip whenever I transition between standing up or sitting down. She also talked a lot about linkage from right shoulder to left lower back (and where the pain is) wondering whether it was linked to R shoulder issues I had 25 yrs ago.

Dead hanging banned too :(

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#348 Re: New 'Physio Clinic' Q&A session
November 28, 2014, 12:23:28 pm
Hi Matt - was having another session when you replied...

She worked my lower back and also hamstring a lot... But spent 15 min hammering my glute (deep) and you could feel it free up...

A week on it feels like someone is twisting a knife deep in my arse/buttock above the hip whenever I transition between standing up or sitting down. She also talked a lot about linkage from right shoulder to left lower back (and where the pain is) wondering whether it was linked to R shoulder issues I had 25 yrs ago.

Dead hanging banned too :(
Hi, it sounds like she is thinking more along the lower back direction. You will often get pain referred into the buttock and it will sometimes become over reactive and try and protect your lower back. Previous shoulder injuries can most definitely cause back pain if you change the way you move or compensate.
All he best
matt

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#349 Re: New 'Physio Clinic' Q&A session
January 05, 2015, 12:55:48 pm
For perhaps the last winter I've had a bit of a niggling in my left shoulder. Since turning to filthy sport climbing this spring, this has started to flare up and tonight I have had to pass up the wall as I've felt it giving me pangs while sat at work today.

Its basically a pain that runs down the rear of my neck (left side) and down into my shoulder blade to a point that feels quite central in my shoulder. This doesn't really hurt while climbing, but after getting on the sport I've certainly noticed it in the days after. Particularly pronounced when I turn my head to the right.  After a session at Malham on Sunday it wasn't great. Went for an 'enthusiastic' swim last night (mainly breast stroke) and today its been pretty poor.

Any idea what this might be and what I ought to do to make amends? Thanks in advance for any help you can give!
Hi it sounds like the problem is coming from your neck more so than the shoulder. The cervical spine will refer pain in to the shoulder, shoulder blade area, arm and even in to the hand and fingers.
The fact that breast stroke irritated it probably means that the neck isn't liking excessive or repetitive extension ie looking up. In the daytime take care that you are not slumping when you sit which tends to promote a forward head position. Often climbers become stiff in their mid back regions and this can affect neck and shoulder positions/movements. Basically try to do some stretches for this area and be more aware of your posture.
I would recommend you see a physio as you have had this since the winter.
Regards
Matt

After studiously not getting round to seeing a physio this has now come to a head. In the past month I've had two "episodes" where I've felt a sudden jolt of pain in the muscle in question (girlfriend tells me its the trapezius) which then makes head movment left, right, up, and down very painful for a number of days. On each occasion this has been set off when drying my hair after getting out of the shower! NSAIDs seemed to help and I've been back climbing on it fairly quickly.
Aside from the 'episodes' I also had a lot of trouble whilst on holiday - long stretches driving the camper van causing short-term discomfort.
I'm off to see the physio tonight so will report back with their verdict. I suspect it is a posture thing (as suggested elsewhere on this thread) that could well be exacerbated by carrying heavy pads up long walk ins, playing the violin etc.
Hopefully will be told I can still climb and train and get some exercises for strenghthening.

So, not after advice as such, just wanted to provide follow up for anyone searching for similar ailments.

 

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