[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.