Modifications for rotator cuff tendinopathy?/Physical Therapy

[MVT]

Hi Mark- After about 4 months on SSLP, I was diagnosed with minor bilateral rotator cuff tendinopathy (without tearing yet). Since then, I have been going through PT for about 2 months now. My therapist has told me some things that conflict directly w SS and now I am confused- things like:
-for bench press & press, the humerus should never go beyond parallel to floor (ie elbows 90 degrees)
-no more military presses for my shoulders, but incline bench to 90 degrees is ok?
-"chinups are bad for the shoulders", especially as I approach 40 yo. I should switch to lat pull instead.
-no more deadlifts to avoid shoulder strain
-I have been doing light weight rotator cuff isolation exercises without any sort of increase in weights/reps

Is any of this valid, or should I find a new therapist? Do you have any advice on finding a therapist who is more familiar with barbell strength training?

My goal is obviously to prevent further damage to my shoulders, but I would also like to get back to my training program asap and continue building muscle mass.

Thanks for your help!

[Mark Rippetoe]

Everybody who thinks that PTs don't really say this shit needs to read this. Aloud. Burn the words into your brain, so that you understand my problems with this fraudulent approach to billing an insurance company. FRAUD is the word I used. Feel free to repeat this.

My question for you is, why did you seek medical intervention for this? Was the pain unbearable? How did the injury arise? Once it was diagnosed (how? MRI?) as minor tendinopathy with no tearing, why did you go to PT instead of correcting the form problems that might have either caused this or exacerbated the pre-existing condition? Do you have access to a SSC?

As the book demonstrates, none of the exercises in the program are anatomically capable of producing this injury, and have been used quite successfully to rehab shoulder injuries that occurred doing other movements. If you are confused, reread the material and post your questions here.

It is not your job to educate your PT, but it should be your job to protest the billing for this patent bullshit. Demand your money back, if you've paid for it yourself, or demand that your insurance company recover the billing. This cannot be tolerated any longer.

[JCavin]

Holy crap.

I used to have really messed up shoulders from years of abuse in martial arts and rock climbing.

The ONLY thing that keeps them healthy is consistent overhead pressing.

My favorite recommendation here is to do LAT PULLDOWNS in lieu of CHINS. What the hell. Get your PT to articulate exactly how it is that PULLDOWNS don't impinge your shoulder while CHINS do. Seriously. What. The. Hell.

[Will Morris]

Hi Mark- After about 4 months on SSLP, I was diagnosed with minor bilateral rotator cuff tendinopathy (without tearing yet). Since then, I have been going through PT for about 2 months now. My therapist has told me some things that conflict directly w SS and now I am confused- things like:
-for bench press & press, the humerus should never go beyond parallel to floor (ie elbows 90 degrees)
-no more military presses for my shoulders, but incline bench to 90 degrees is ok?
-"chinups are bad for the shoulders", especially as I approach 40 yo. I should switch to lat pull instead.
-no more deadlifts to avoid shoulder strain
-I have been doing light weight rotator cuff isolation exercises without any sort of increase in weights/reps

Is any of this valid, or should I find a new therapist? Do you have any advice on finding a therapist who is more familiar with barbell strength training?

My goal is obviously to prevent further damage to my shoulders, but I would also like to get back to my training program asap and continue building muscle mass.

Thanks for your help!

Forget the diagnosis for starters. Your diagnosis is simply "shoulder pain". Your shoulder pain after beginning the linear progression was probably because your bench press technique sucked, you added some additional exercises, or you have a job where you sit for most of the day. Shoulders hurt, and not all shoulder pain is because something is damaged. Sometimes things just hurt.

Your PT is simply parroting what they have heard but has never put any mechanical analysis into why they make such recommendations. That said, if you were to visit 100 orthopedic surgeons, 100 family practice physicians, and 100 chiropractors, a resounding majority would say that your PT's recommendations are sound. But, these recommendations are complete horseshit. Ask what qualifies as a military press, and most of them will describe a behind the neck press, but then again, most healthcare providers will default to saying you should never do any activity over your head.

[Clay Simczyk]

Late last year I scheduled surgery for a torn labrum in my right shoulder. That surgery was cancelled, on the advice of the surgeon, because I had basically recovered too much to justify it. The only things I did as rehab were the overhead press and chin ups. (And my humerus went past parallel - whatever the fuck that means.)

[Mapman]

I have a similar story. Went to a PT for chronic neck pain. PT performed some funky modalities (my new favorite word at the time). Lots of medieval neck torture and lots of bosu ball exercises. Nothing ever resolved. I started SS shortly before and my neck and a host of other issues resolved themselves.

I did leave a copy of the academic paper about valsalva that was produced a while back on the waiting room coffee table. It's my little passive-aggressive thing.

[DoctorWho]

Also similar story. Shoulder diagnosed as having chronic tendinitis or chronic bursitis, with several cortisone shots during wrestling season decades ago (before mris). Couldn't throw a baseball more than a few times without lots of pain near where the supraspinatus attaches (self diagnosed). I could not get under the bar when I started SS about three years ago, but the doc asked me to try physical therapy even before he would send me for an mri. The PT diagnosed my shoulder as having almost zero capability for internal rotation and put me to work with stretching and tiny "strengthening" exercises. I stopped going after 2 or 3 times because the stretching exercises let me get under the bar. Now my shoulder is very nearly 100%, and the best its been since I was 15. I think OHP work is the reason.

[MVT]

Thanks everyone for the replies! In response to all the questions above:

My question for you is, why did you seek medical intervention for this?

-I have psoriatic arthritis, and went to my doctor to check that the pain wasn't related to underlying joint damage from that... to make sure I could continue working out without making joints worse.

Was the pain unbearable?

-No, initially I only felt it during certain exercises but it started to persist between workouts (see below). Never unbearable though.

How did the injury arise?

-I first noticed the pain during bench presses. At the very bottom of a rep when the bar was near my chest I had some focal anterior shoulder pain on the left as the bar changes direction. (Oddly enough I found that if I press on my infraspinatus posteriorly with a small massage ball it actually reproduced the anterior pain- not sure what that was all about). I then developed a similar focal anterior pain on my right shoulder that I felt more during chin-ups than bench press at the bottom of each rep- also reproducible with posterior pressure on my right infraspinatus. At that point I went to doctor. I was not doing any accessory work besides chin-ups, which I added only after a few months of LP. More recently, I have noticed that squats also seem to aggravate the problem, particularly with racking the bar. I also have a desk job where I sit most of the day.

Once it was diagnosed (how? MRI?) as minor tendinopathy with no tearing, why did you go to PT instead of correcting the form problems that might have either caused this or exacerbated the pre-existing condition?

-Diagnosed on physical exam by my primary care doctor, did not have an MRI. Went to PT based on doctor's advice for addressing rotator cuff. Didn't think form was the issue since I've read your books, watched your DVD, and have recorded myself to check and adjust form as needed. In hindsight, I probably should have gotten some coaching to make sure form was really ok, but that was not the obvious solution at the time based on my own assessment of form and doctor's advice.

Do you have access to a SSC?

-No, there are none closeby.

Based on all that, what should I do now? At the advice of my PT, I haven't done bench or press in 2 months and I stopped deadlifting 1 month ago. It sounds like I should find a coach somehow so that I can work on form, and based on the recs in SSPP, I could restart those exercises with a 20% reduction from where I left off?

[Mark Rippetoe]

Looks like you're going to have to get in the car and drive to a coach or a seminar.

[hollismb]

Everybody who thinks that PTs don't really say this shit needs to read this. Aloud. Burn the words into your brain, so that you understand my problems with this fraudulent approach to billing an insurance company. FRAUD is the word I used. Feel free to repeat this.

An article from the NASM entitled 'Preventing shoulder and rotator cuff injuries through corrective exercise programming' popped up in my Facebook feed last night that does a really good job of illustrating their approach (here's the link, feel free to remove it):

Many exercise protocols tend to place an emphasis on compound movements and load training and do not include enough movements focusing on motor control. But for injury prevention and proper strengthening of the shoulder complex it is important to progress clients appropriately with a multi-phased approach including motor control, isolated strengthening and integrated dynamic movements. (7)

Teaching motor control should include a variety of cues including visual and verbal. (8) No weight should be used at first with the goal of developing perfect movement patterns in flexion, abduction, scapular plane, external and internal range of motion. This will become the baseline of movement to build from. Any alterations of perfect movement such as scapular winging, asymmetrical trapezius activation or compensatory cervical, thoracic or lumbar motion when weight is added would require a regression of less weight, changing to a more stable position or surface, or a combination of all. Although core stability is not the purpose of this article, it should be assessed as a strong core providing proximal stability will allow proper distal mobility and movement patterns of the shoulder.

Once proper motor control has been attained along with scapular stability, rotator cuff strengthening exercises can be integrated. Strengthening the external rotators is important as weakness of the teres minor and infraspinatus is a potential cause for shoulder impingement as well as other conditions. Therefore maintaining an appropriate strength ratio of 66-75% of external to internal strength is critical here (12).

Note that almost all the exercises are done with a resistance band or very light dumbells, while either lying on the floor or sitting on a stability ball for three sets of ten reps.