Your thoughts on dealing with shoulder impingement....

[Kiknskreem]

Here's the deal Rip.... I'm a competitive powerlifter with a shoulder injury.

I have pain in the shoulder joint that precludes virtually all upper body pressing as well as any type of pullup. I can back squat, but I am always inflamed afterwards. So it is hampering my training in general, especially upperbody.

Years ago before being a serious lifter I was diagnosed with bursits in the same shoulder, went through PT (which seemingly didn't help), stopped "lifting" and it just resolved itself over time.

Over the last year and a half or so I had intermittent pain in the shoulder, typically I responded by taking some time off OH work, which aggravated it. I trained through it for the most part up until my last meet in October, after which I simply couldn't train through it anymore. Haven't really benched or pressed since, but I have found ways to continually aggravate it countless times.

After putting it off for FAR too long, I went to the doc. X-rays showed nothing. An arthrogram MRI showed a small fissure in the cartiledge, which the doc says didn't believe was causing problems and no need for surgery. No firm diagnosis, other than "could be instability or impingement, yada yada". No real answer and recommended me for PT.

I am not big on doing PT for an extended time for such a nebulous diagnosis.

I am inclined to believe it is just simple impingement. My plan of action now is avoid any aggravting exercises, ice it frequently, and planning on taking IBpreufon twice daily. I am also seeking a second opinion, as well as waiting to hear back from my first doc on the possibility of getting a cortisone shot.

I believe the problems originated in improperly locked out OH presses and too widely gripped bench presses. The doc I went to, although a well known orthopedist (apparently worked for the Eagles) didn't seem to know much about weight training, didn't question me about my level of development (I coulda been a kid just fuckin' around with 15lb DB's in my basement for all he knew) or anything like that.

I was hoping you might have some feedback or guidance on this issue.

I know this must have been quite a read, but if you made it this far, thanks for sticking with it.

[Mark Rippetoe]

If you believe this is simple impingement, and you don't think the tear is a factor, up the ibuprofen to 800mg x 4/day for 5 days, and then start the Starr rehab with presses, making sure to shrug into the lockout. But add this as a warmup: hang with a pullup (prone) grip for several 15 second reps from the bar, then several more with a chin grip (supine). Then do a couple of sets of 20 light lat pulldowns with a chin grip. This should prepare the shoulder capsule for the pressing.

Do presses only for 3 months after this is healed, and then re-introduce benches with a moderate grip, and from then on do your benches 1:1 with presses. This keeps the shoulder in balance, and prevents these kinds of problems.

[Kiknskreem]

If you believe this is simple impingement, and you don't think the tear is a factor, up the ibuprofen to 800mg x 4/day for 5 days, and then start the Starr rehab....

I am scheduled to get a cortisone injection tomorrow. Should I bother to continue with the ibeuprofen or will its effects simply be eclipsed by the cortisone shot?

I had been planned on introducing some other rehab exercises (lying external rotations, scap protactions, going through a few progressions on these exercises) but will scrap that plan and apply the Starr method with presses.

I read through the Starr method and had question. Am I devoting a full 10 days to each rep range? There was some refrence to a two week duration in the injury outline.. so I am unsure.


Here's my tenative outline, if I have understood correctly....

5/13- Cortisone shot/IBpreufon treatment
5/18- Begin Starr rehab only, no other lifting
5/28- Begin 15 rep range
6/8- Begin 10 rep range
6/18- Begin 5 rep range
6/28 - Resume normal training
9/18 - Reintroduce Bench press

[Mark Rippetoe]

Stop the ibuprofen if you're getting the shot. No point in having both medications when the shot is the more specific and powerful of the two. The Starr deal lasts for a total of 2-3 weeks, so plan accordingly.

[robertdawson]

Great info Coach. Sticky worthy? Maybe edit out some of the specific stuff for his situation and just name it "How to fix shoulder impingement"

[MadDwarf]

Here's another data point you can ask your doctor about. I had similar shoulder pains that built up over a couple of years, peaking at the end of 2006, at which point I couldn't manage even light weights overhead without flinching. I initially thought the issue was shoulder impingement, but a physician that took the time to fully analyze the pain through full range of motion determined that it was osteoarthritis in the AC joint.

In that case, it can also sometimes be treated with cortisone and/or ibuprofen and ice. Mine ended up in surgery, but it was fairly simple, and recovery was quick.

One interesting thing was that they can use the cortisone injection to help verify the diagnosis. Before they administered the cortisone, they injected the area with a pretty good dose of very localized anesthetic. The doctor's advice was to find something moderately heavy to play around with during the couple hours before the anesthetic wore off. If he was treating the right area, there should be no pain lifting overhead, or moving in directions that normally bothered the shoulder.

[Kiknskreem]

Gotcha.

Got my shot today... the doc wants me to take a few weeks off in order to let the inflammation settle down.

I happen to trust your empirical experience with lifters more than this doc... but I musk ask about the short duration between treatment and beginning rehab... if the issue is simple impingement... will I not simply run the risk of aggravating it again by resuming presses so soon?

Or do the injections/IB treatment yield significant enough reductions in inflammation in such a short duration that rehab can be started?

Again, thanks for taking the time. This is my first serious injury and I feel much better having you in my corner.

[Mark Rippetoe]

You will not aggravate the impingement with good, correct form because correct form does not impinge. The anti-inflammatory meds start the cooling-off process, and the correct rehab helps break up the inflammation too.

[Kiknskreem]

You will not aggravate the impingement with good, correct form because correct form does not impinge....

I suppose... perhaps the divide lies in my understanding of the condition.

I understand it as such...once the tendonds/soft tissue become inflamed, even natural, anatomically correct movement can further aggravate the condition, because where otherwise there would be enough space for soft tissue clearance, there no longer is. Thus, even correct movement further inflames the tissue and leads to a vicious cycle which can result in increased pain, decreased RoM, and eventually possible tendon rupture.

Because of this, it seems that resuming lifting (even with correct form) could still make the impingement worse as the inflamed tissues occupy space where they should not, even when correct mechanics are used.

So that's my link of thinking on this. From what I have gathered tendons heal slowly because of low blood supply, and that therefore a longer time than the 5 day Ibprofen protocol (or in my particular case, the cortisone shot) might be desireable.

Would you explain some of the processes (or just a general description) of how the rehab protocol helps break up inflammation, and where my description above goes off-track?

Lastly, you said to stop the Ibprufon if I was getting the shot. Now the IB treatment was 5 days duration before starting rehab... what would the time span be with the shot?

[Mark Rippetoe]

If you're already inflamed and the swelling is such that the tendon is bigger than the space it normally occupies, then yes, you'll have to take some steps to get the inflammation down before you start back. The cortisone shot immediately blocks the production of any new inflammatory products at the top of the cascade, and it should exert its maximum effect quite soon after the injection -- 48-72 hours -- and after this you can start back training light. The training acts the same way a friction massage does, by physically mashing the inflamed tissue to push out swelling, edema, and increase the normal circulation provided by the peritenon. In fact, if you have not yet had a friction massage you need to get one.

Here is another way to think about inflammation that has some potentially interesting implications for the management of chronic inflammation: http://www.answerbag.com/q_view/185648