[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.