Frustrating Shoulder Injury (Possible Tendinopathy)

[Will Morris]

Uh...deep to the supraspinatus? The only thing that comes to mind is the subscapularis. I feel like I’m misunderstanding you.

The subscapularis would be deep to the scapula. Do you have a Netter's Atlas handy?

What are the classic tendons in the body that are most susceptible to tendinopathy? What characteristics do they share?

[Devyn Stewart]

Sure, but I don't see a muscle deep to the supraspinatus but superficial to the scapula. I don't want to disappoint, but if there's a muscle that fits that description, I don't think I've heard of it. I should mention that I'm not in a DPT program (yet), and my anatomy/physiology knowledge comes from the intro level class at my university and from being around lifting for a while, but the formal training for me is definitely less than extensive.

I mean, the most common that I see at the clinics I volunteer at are achilles and medial/lateral epicondylitis, but in terms of the shoulder, it tends to be rotator cuffs, most often the supraspinatus. I believe their commonalities are that they tend to be heavily loaded during movement like jumping or swinging. In the case of the supraspinatus, that would be lots of throwing or various overhead work. Generally it happens because of an increase in volume, but I don't think that fits my situation, as it happened near the end of LP. Unless, of course, the stimulus for the injury was the increased weight, which I presume is possible.

Is this where you wanted me to go with this?

[Devyn Stewart]

It seems as though this thread has died, but I will add in an extra piece of information in case this matches anyone else's experience. I attempted to squat very light (the empty bar), and it still left my shoulder feeling pretty irritated the next morning. It seems as though the act of getting into the squatting position is what irritates it the most, not necessarily the weight itself.

[Dust Devil]

That's interesting. How would I go about looking for trigger points?

To respond to a later post of yours, my pain also was getting into the squatting position, nothing to do with the amount of weight.

The "Trigger Point Therapy Workbook" can generally guide you to the right area, but after that, you have to poke around a bit with something hard until you find a spot that hurts. A lacrosse ball lets you roll it around, which helps finding the spot, but my spot was a little too hard to access for the lacrosse ball.

The rotator cuff muscles are often points of trouble and one strategy would be to treat each of them and see which one hurts.

[Devyn Stewart]

I see. I appreciate the input, though I still have reservations that this is a "trigger point" problem. From what I found when I googled the term, trigger points produce a dull ache on the trigger point, while my pain is very clearly on a tendon insert. More data from the past week has convinced me that this nearly has to be related to my trapezius, although Will Morris seemed to disagree. Right now, although I hate it, my best judgment has convinced me to cease irritating movements like squats and presses (praying that today's workout with bench sans squats will be okay, but I may not be able to bench either) while I attempt to rehab the injury.

feelsbadman.jpg

[Will Morris]

Sure, but I don't see a muscle deep to the supraspinatus but superficial to the scapula. I don't want to disappoint, but if there's a muscle that fits that description, I don't think I've heard of it. I should mention that I'm not in a DPT program (yet), and my anatomy/physiology knowledge comes from the intro level class at my university and from being around lifting for a while, but the formal training for me is definitely less than extensive.

I mean, the most common that I see at the clinics I volunteer at are achilles and medial/lateral epicondylitis, but in terms of the shoulder, it tends to be rotator cuffs, most often the supraspinatus. I believe their commonalities are that they tend to be heavily loaded during movement like jumping or swinging. In the case of the supraspinatus, that would be lots of throwing or various overhead work. Generally it happens because of an increase in volume, but I don't think that fits my situation, as it happened near the end of LP. Unless, of course, the stimulus for the injury was the increased weight, which I presume is possible.

Is this where you wanted me to go with this?

What is the general structure of tendons that are frequently indicated at being "at risk" for the development of tendinopathy? Further, what is the general treatment for tendinopathy?

[Devyn Stewart]

What is the general structure of tendons that are frequently indicated at being "at risk" for the development of tendinopathy? Further, what is the general treatment for tendinopathy?

Well, take everything I say as conjecture rather than studied fact, as I'm still very much a student of all this. That being said, tendinopathies tend to result from overload. It makes sense, then, that the most common tendinopathies are in the lower body (patella, achilles). These tendons in particular are multimuscular. More than one muscle loads the tendon, which contributes, I imagine, to the overload. I've been skimming the research a bit as well, and it appears that there is a shift in collagen type in tendinopathic tendons, though the scientific community isn't entirely sure which direction the cause and effect points.

General treatment for a tendinopathy, depending on the PT of course, is proper loading of the tendon, preferably with eccentric movements progressing to increased resistance. There has been some evidence that things like NSAIDs or ultrasound treatments may be worth something a bit more than placebo in terms of temporary pain relief, but generally the eccentric loading is what tends to do the trick.

[Will Morris]

Well, take everything I say as conjecture rather than studied fact, as I'm still very much a student of all this. That being said, tendinopathies tend to result from overload. It makes sense, then, that the most common tendinopathies are in the lower body (patella, achilles). These tendons in particular are multimuscular. More than one muscle loads the tendon, which contributes, I imagine, to the overload. I've been skimming the research a bit as well, and it appears that there is a shift in collagen type in tendinopathic tendons, though the scientific community isn't entirely sure which direction the cause and effect points.

General treatment for a tendinopathy, depending on the PT of course, is proper loading of the tendon, preferably with eccentric movements progressing to increased resistance. There has been some evidence that things like NSAIDs or ultrasound treatments may be worth something a bit more than placebo in terms of temporary pain relief, but generally the eccentric loading is what tends to do the trick.

I'll take conjecture right now, because at least you are thinking about this. In the span of several thread posts, you have started to learn more about tendinopathy rather than just be given some prescription for treatment. You have already started to show a deeper understanding of the topic. The anatomy assignment got you to thinking more about the area, because, as a future PT, you always have to consider the other structures in the area, as well as the areas that refer pain to the area in question.

For chronic trapezius-related pain, especially in a training population, don't forget the 1st rib. A 1st rib dysfunction can masquerade as myofascial pain in the trap, and the myofascial pain tends to be recalcitrant to soft tissue treatment. It will also cause a pronounced myofascial trigger point production in the upper trap.

For tendinopathy, the usual suspects are tendons with long attachments relative to the muscle. Long tendon bodies will allow for there to be a rotational component to loading which is further compounded by multimuscular attachments. The patellar tendon, Achilles tendon, rotator cuff tendons, and biceps tendons are all long tendon bodies. There just doesn't seem to be much in the way of diagnosable tendinopathy in broad based tendinous insertions, as we see in the trap. Certainly, statistics doesn't take away a tendinopathy as a differential, but there may be more to consider here.

As far as treatment, eccentric loading has been shown to produce decreased pain, however eccentric loading protocols tend to have exceptionally poor compliance. The Beyer et al RCT from 2015 randomized eccentric loading against heavy, slow resistance training and showed a slight advantage to HSR. As such, my general prescription for tendinopathies is heavy, slow resistance training and very few individuals get strictly eccentric loading anymore. HSR gives improved function, equally good pain reduction, and higher overall patient satisfaction at 3 months than eccentric only.

[Devyn Stewart]

I'll take conjecture right now, because at least you are thinking about this. In the span of several thread posts, you have started to learn more about tendinopathy rather than just be given some prescription for treatment. You have already started to show a deeper understanding of the topic. The anatomy assignment got you to thinking more about the area, because, as a future PT, you always have to consider the other structures in the area, as well as the areas that refer pain to the area in question.

For chronic trapezius-related pain, especially in a training population, don't forget the 1st rib. A 1st rib dysfunction can masquerade as myofascial pain in the trap, and the myofascial pain tends to be recalcitrant to soft tissue treatment. It will also cause a pronounced myofascial trigger point production in the upper trap.

For tendinopathy, the usual suspects are tendons with long attachments relative to the muscle. Long tendon bodies will allow for there to be a rotational component to loading which is further compounded by multimuscular attachments. The patellar tendon, Achilles tendon, rotator cuff tendons, and biceps tendons are all long tendon bodies. There just doesn't seem to be much in the way of diagnosable tendinopathy in broad based tendinous insertions, as we see in the trap. Certainly, statistics doesn't take away a tendinopathy as a differential, but there may be more to consider here.

As far as treatment, eccentric loading has been shown to produce decreased pain, however eccentric loading protocols tend to have exceptionally poor compliance. The Beyer et al RCT from 2015 randomized eccentric loading against heavy, slow resistance training and showed a slight advantage to HSR. As such, my general prescription for tendinopathies is heavy, slow resistance training and very few individuals get strictly eccentric loading anymore. HSR gives improved function, equally good pain reduction, and higher overall patient satisfaction at 3 months than eccentric only.

I see. I appreciate you eventually taking pity on me and giving me some direction! I have definitely learned about tendinopathies as I've obsessed over figuring out what's wrong with me.

I'm not sure I totally understand your point about the 1st rib. What kind of dysfunction in the 1st rib are you referring to? Also a tendinopathy? If so, which muscle/movement types should be treated?

Oh, that makes sense. I guess identifying the patella and achilles didn't quite get me to that conclusion, but I will be sure to remember it going forward.

I would love to participate in heavy, slow resistance training. It's just that the only progress I've made has been counteracted by reaggravating the area with the movement that caused the problem. It would feel like I was taking a step forward with my self-prescribed therapy and then taking two steps backward with strength training. Do you recommend ceasing irritating movements, or would you try and find a way to continue squatting/pressing? (Just for reference, the empty bar on squats was enough to cause significant pain for a day)

I really appreciate your help, Will. I hope I can learn more from you and your peers going forward.

[Devyn Stewart]

Update for those who care:

I took serious consideration into everything that was suggested here (tendinopathy, trigger point, 1st rib dysfunction), and I think I may have stumbled upon the cause. I was feeling around attempting to palpate my first rib (probably something I shouldn't be trying to teach myself), and I found a golf ball sized knot in my left trapezius. It's extremely sensitive to touch and pressure, so it looks like the trigger point hypothesis might have some merit. I never thought a knot would cause so much pain, and I guess I'm still not sure that that's the cause of pain, but I've got a strong lead on the problem!

I'll be sure to give updates as this unfolds.