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Thread: Dry Needling in case of a shoulder impingement

  1. #81
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    Quote Originally Posted by Will Morris View Post
    Look up calcific tendinosis.
    Yes this might be it. But there is very little info about it online in relation to weightlifting and almost non on the forum. Do you have any experiences with treating it?

    Quote Originally Posted by novicejay View Post
    I had a similar diagnosis. The ortho said surgery. The pain management guy said shots. I could not move my arm above my head. If I physically raised it higher than my shoulder it burned like fire. Every day, I took fish oil, etc. for inflammation. I then forced my arm up one half-inch at a time. I then pressed the broom. I then put empty buckets on the broom. I then put some dirt in the buckets. I got it to where I could press the bar. I then pressed my way out of pain and out of surgery. I can't thank Coach Rippetoe enough for that because it eliminated an unnecessary surgery.
    I'm not sure I understand - was it at one point physically impossible for you to extend your arm overhead? Because I don't have such an issue, it just hurts like hell.

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    Quote Originally Posted by 2) The Answer is Texas View Post
    Yes this might be it. But there is very little info about it online in relation to weightlifting and almost non on the forum. Do you have any experiences with treating it?.
    Well, that depends. Do you believe the calcium embedded in the biceps tendon is what is causing your pain, or do you believe it is the bursitis?

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    Quote Originally Posted by Will Morris View Post
    Well, that depends. Do you believe the calcium embedded in the biceps tendon is what is causing your pain, or do you believe it is the bursitis?
    This might be a stupid question so I apologize in advance. But is it possible for me to distinguish those pains ? If so, how?

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    Quote Originally Posted by 2) The Answer is Texas View Post
    Yes this might be it. But there is very little info about it online in relation to weightlifting and almost non on the forum. Do you have any experiences with treating it?



    I'm not sure I understand - was it at one point physically impossible for you to extend your arm overhead? Because I don't have such an issue, it just hurts like hell.
    Yes, it hurt to even straighten my arm out in front of me. I have ABSOLUTELY nothing to prove this and I think Coach would be the best person to ask but I'm guessing the muscle moves the bones and since I got the muscle moving it created the space so that I didn't have the pain any longer in my shoulder. It hurt unbelievably bad to do that. I don't know if that will work for you. I just know it worked for me.

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    Quote Originally Posted by 2) The Answer is Texas View Post
    This might be a stupid question so I apologize in advance. But is it possible for me to distinguish those pains ? If so, how?
    You've already distinguished between the two by stating what your symptoms are. You stated you felt a burning knife sensation in your shoulder at the lockout of the press, correct? Does this sound like pain that would be caused by having calcium embedded in the tendon? Do young boys who have Osgood Schlatter's Disease have burning knife sensation in their knees?

    The answer is no. These types of problems (when symptomatic) are sore to the touch and they take a long time to warm-up. They bother the patient more after activity than they do during the activity.

    Now, doesn't burning pain seem to be more consistent with bursitis? Here's the deal, even though you feel better that you have a "proper and objective diagnosis", the calcific tendinosis is almost certainly an incidentaloma on imaging. The bursitis is causing the pain, which is why your PT gave you the diagnosis of "shoulder impingement". Bursitis is also consistent with your reported history. Bursitits is treatable, but there is likely some form problems with your lifting, or things you do in daily life that lead you susceptible to having this (i.e. sitting at a computer for a long period of time each day).

    This is an important lesson to everyone on this board. Advanced imaging is a diagnostic tool that is used to confirm a clinician's diagnosis when that diagnosis will likely require surgical intervention, or it is used when the findings of the imaging are going to significantly change the course of treatment for that patient. Let me give you an example: two patients come in with knee pain. The first patient reports they had a rotational injury three days ago, and they present with a large knee effusion and they have a positive Lachmans test (which tests the integrity of the ACL). The patient is walking with a grossly antalgic gait and already have significantly reduced tone in their quadriceps. The second patient comes in and says they had a knee injury while playing football 15 years ago. The patient didn't have insurance at the time, but his knee got better. Over the past three or four years, it is really stiff in the morning and takes about a half hour to get moving well. The patients reported symptoms are most consistent with osteoarthritis, and the patient does not demonstrate laxity of the ACL.

    These two have exactly the same "injury" on advanced imaging, but which one of these two needs an MRI? I'd hope everyone can agree that the first needs an MRI, as he likely had a catastrophic failure of the ACL, and given his presentation, he will likely be a surgical candidate. The second patient had an ACL tear from his football injury 15 years ago, but why would we not refer him to ortho to have his ACL reconstructed? You have to understand that pathoanatomy only gives you a piece of the puzzle. Your clinical presentation is much more powerful than what imaging says. If I full body MRI a thousand people, you wouldn't believe the "injuries" you will find in someone who is completely asymptomatic. Having pain along with advanced imaging that is abnormal does not prove causation.

  6. #86
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    Quote Originally Posted by Will Morris View Post
    You've already distinguished between the two by stating what your symptoms are. You stated you felt a burning knife sensation in your shoulder at the lockout of the press, correct? Does this sound like pain that would be caused by having calcium embedded in the tendon? Do young boys who have Osgood Schlatter's Disease have burning knife sensation in their knees?

    The answer is no. These types of problems (when symptomatic) are sore to the touch and they take a long time to warm-up. They bother the patient more after activity than they do during the activity.

    Now, doesn't burning pain seem to be more consistent with bursitis? Here's the deal, even though you feel better that you have a "proper and objective diagnosis", the calcific tendinosis is almost certainly an incidentaloma on imaging. The bursitis is causing the pain, which is why your PT gave you the diagnosis of "shoulder impingement". Bursitis is also consistent with your reported history. Bursitits is treatable, but there is likely some form problems with your lifting, or things you do in daily life that lead you susceptible to having this (i.e. sitting at a computer for a long period of time each day). (...)
    I really appreciate you taking your time for this.

    Yes, the lockout of the Press and the descending portion of the Chin-up feel as if someone is stabbing me in the shoulder. I'm guessing this is because the humerus is pressing down on the affected swollen bursa in those positions, is this correct?

    The diagnostician said the bursa was most likely irritated by either the calcium deposits or a wrong technique - or both. How much calcium was present or how old the calcium on the tendons are wasn't immediately clear. So you are right that the calcium might just be a remnant of those old 1-PR bro-bench presses of years ago. I'll report back about this once I speak to my GP tomorrow.

    I've taken a break from lifting for 2-3 weeks as is the ''conventional' advice" to see if that fixes it. But my pain hasn't decreased. I want to restart training. Are any modifications to SS necessary due the bursitis? Should I avoid the Press/Chin due to the pain or train through it? (After providing a video, of course.) Because "conventional wisdom" seems to state you shouldn't train with 'sharp pains'. In some shoulder pain-posts Mr Rippetoe's advice seems to be to avoid the Bench press and do the Press instead, but for me the Bench Press is less painful than the Press.

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    Quote Originally Posted by Will Morris View Post
    Now, doesn't burning pain seem to be more consistent with bursitis?
    I've been thoroughly enjoying your input on this topic, Will, and I thank you for sharing your expertise. In a perfect world, what would you recommend for the treatment of shoulder bursitis? Would you recommend anything different for the treatment of bursitis of a different joint? As a trainer I refer out to physiotherapists and sports doctors, but as this board is acutely aware, this often produces suboptimal results. I would love to have your input so that I may better gauge when my clients are on the right path to recovery.

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    Quote Originally Posted by JasonJones View Post
    I've been thoroughly enjoying your input on this topic, Will, and I thank you for sharing your expertise. In a perfect world, what would you recommend for the treatment of shoulder bursitis? Would you recommend anything different for the treatment of bursitis of a different joint? As a trainer I refer out to physiotherapists and sports doctors, but as this board is acutely aware, this often produces suboptimal results. I would love to have your input so that I may better gauge when my clients are on the right path to recovery.
    Well, first of all, you have to find the cause of the bursitis. More often than not, especially in our population, it will come down to one, or a combination of, 3 factors: 1) shitty sitting posture coupled with long hours spent behind a computer screen, 2) shitty bench press or shoulder press technique, 3) or the person is a closet bodybuilder, or, they are doing the program but adding a whole bunch of extraneous sets and reps (you see this often with the guys that claim, "I need more volume for my chest or it doesn't grow").

    For the rest of the population, it is almost always terrible sitting posture (shoulders rounded forward which closes down the subacromial space).

    No matter what you treat shoulder bursitis with, if you don't address the causative factor / factors, the bursitis will return without exception.

    All that said, my standard treatment for shoulder bursitis (in a lifter and pain is not off the charts):
    1) On day 1, I have them show me how they bench press and I correct their bench press to the Starting Strength standard. If they are a little more symptomatic, I will have them lay off the barbell for 2-3 weeks and substitute dumbbell presses with a technique I developed.
    2) I teach this patient how to perform bent over barbell rows, and I stress how important it is they do not add additional bench workouts, or add additional sets / reps.
    3) They get a few ideas on how to reverse time spent at the computer. The only good use of a BOSU ball is to put under your thoracic spine for 5-10 minutes after you've spent several hours behind a keyboard.

    Within 3-4 weeks, they should be able to switch back to a barbell without any pain. If they still have some residual pain but everything else has been addressed, I consider sending them for an US guided corticosteroid injection. I don't do this often because the evidence is pretty clear that this leads them more susceptible to rotator cuff tendon tears in the future, but, at times, it is a very powerful treatment option....if used properly. If it is used too soon, the patient will feel better and decide to throw an additional three or four chest workouts into that week, and as soon as the CSI wears off, they have crippling shoulder pain.

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    All right, I just met with the GP. Mr Rippetoe was right all along and I'm happy that I came to this board in the first place.

    1. The final findings of the diagnostician:

    A) There are small calcium deposits on the infraspinatus tendon, indicating that the tendon was overburdened/inflamed at one point or another (calcified tendinitis). However, given the location of the calcium deposits, it's impossible for them to cause the impingement pains that I'm experiencing.

    B) There seemed to be a (slight) swelling of the bursa, but more careful examination showed nothing out of the ordinary. No bursitis.

    C) There are no structural problems in the shoulder.

    2. The testosterone test: LOW. They measured 7,5 while normal levels are between the 9-34. (No idea in which units) The GP seemed almost more surprised than I was. So I can't thank you enough Mr Rippetoe for making me take the bloodtest in the first place. The GP prescribed me tablets.

    Hopefully this will fix my physical problems. I might even get to finish law school now if this fixes my depression issues.

    I can't thank you enough Mr Rippetoe.

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    There are no oral testosterone supplements.

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