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gogo
Oct 8, 2008, 4:42 AM
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Hi y'all -
So the last time I posted on here I think was a couple of years ago when i injured my right shoulder, tweaked out on a campus move. Tore the rotator cuff some, took about a year to heal up, which was hindered by my job as a routesetter and my poor decisionmaking in continuing to routeset. The shoulder felt great for the next few years, climbed harder than ever, and then . . .
January 2008, my left shoulder started feeling hurt. Two months off, just conditioning, running, etc, and a failed climbing trip, and then two months of PT for bicipital tendinitis. Shoulder stronger, but still painful with specific movements and can't handle push-ups or climbing.
The first time I tried to climb after PT, I had a hold spin and over-extended my right with a little "pop" from the trapezius/shoulder area - no pain in the shoulder itself, but a lot of constant tension in my right trapezius.
August 2008 - see a sports med and get an MRI with contrast dye. The MRI technician thinks there is a tear to the labrum, so refers to the surgeon. The shoulder surgeon believes that there is no tear to the labrum, does diagnostic injections (first into where they thought the tear was, then the ac joint) with no relief, but an anesthetic to the sub ac space and bursa has me doing push-ups, full ROM, great - for a few hours. Was strange because the pain was right on the bicep tendon area, but the shot to the side of the shoulder is what cleared it up.
Last Wednesday - The doc does a cortisone shot - I know these are last resort for many people, but its been 10 months and it still seems less extreme than surgery. Also suggests that I see a chiropractor and that it could help with the perpetual tightness in the trapezius. Seeing him tomorrow.
Here's the question (at the end of my rant) - has anyone dealt with bursitis/tendinitis for this long and had it be the problem? The MRI showed the bicep tendon and rotator cuff tendons looking intact, both shoulders have full ROM, but the trapezius' flare up on both sides when I try to use it.
Advice? Experiences? I want to climb.
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onceahardman
Oct 8, 2008, 4:33 PM
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Hi gogo...
This is the most definitive diagnostic procedure you have had, IMO:
In reply to: an anesthetic to the sub ac space and bursa has me doing push-ups, full ROM, great - for a few hours.
Subacromial bursitis can be a very stubborn and difficult condition. Hopefully, the steroid injection (cortisone shot) you received was put in the right spot, and you should have good relief now. Don't make the mistake of thinking that "no pain" means "healed", though. Do your rotator cuff exercises, and some gentle ROM, especially flexion, palm up.
Lots of structures refer pain to the trapezius area, including AC joint, glenohumeral joint, and cervical spine. That may be why a trip to the chiro was recommended.
How is your rotator cuff strength? Has it been tested recently? A weak cuff can cause impaired scapulo-humeral rhythm, which can make trapezius (and rhomboids) work harder than usual. Also, a little hint: find an exercise to work serratus anterior, which has reciprocal innervation (and opposite action) to middle traps, and rhomboids.
If this was an easy diagnosis and treatment, you'd have been better by now.
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gogo
Oct 8, 2008, 6:59 PM
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Yeah, doing the diagnostic injections was one of the first times I felt like I was making progress - it had previously been see a doc, get a referral for an MRI. Two weeks later, get an MRI, get a referral back to the doc, get a referral from the sports med to the surgeon. Two weeks later, go over the MRI with the surgeon. Hold insurance's hand the entire way.
It was also a major relief that the anesthetic into the anterior labral area didn't immediately fix the pain, which would have made surgery much more likely.
Saw the chiro this morning for an exam to see on how we should proceed - x-rays show that I have probably separated my a/c at some point in the past few years on the right, which has caused some muscle imbalances on that side. He also felt that increasing my flexibility was a priority, because of really tight pectoral muscles.
RTC strength is pretty good - work with the medium and strong resistance thera-bands for internal/external rotation. Some exercises, like bent-over lateral raises, didn't work out well with my left, so hopefully some guide PT with the cortisone will let me balance that out.
Yeah - if only it was easy diagnosis easy fix - but whatever - if I can climb again, its all worth it.
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gogo
Oct 14, 2008, 2:07 AM
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I guess its also worth it to ask if anyone has dealt with a labral tear and been able to climb without surgery - or do much anything active with a torn labrum - I'm missing general exercise aside from the stationary bike.
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Sarah_Sunshine
Oct 14, 2008, 2:11 AM
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energy healing
do a search for reiki. there are other kinds too.
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kylerose
Oct 14, 2008, 4:22 AM
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I second everything that oncehardman says. Good stuff. I'm surprised about the cortisone shot. That doesn't seem useful. Look at a second opinion, as surgery may be warranted. Good luck
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gogo
Oct 14, 2008, 4:57 AM
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Thanks - working on getting a 2nd opinion from some other reputable surgeons in Seattle.
I was surprised about the cortisone also; gotten mixed reviews on it, most seeing it as a band-aid solution. I figure that if it works, at least it lets me know that some of the symptoms are caused by inflammation.
it still feels more painful afterwards that it has before, but I was also told it can take weeks before I start feeling it. Though one of the motions that used to really hurt (lateral raise to help rehab, from "training for climbing") actually feels better with the cortisone.
Wondering what else causes a positive active compression (O'Brien's test), since it looks like labral damage is what it is specific for.
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onceahardman
Oct 14, 2008, 5:11 PM
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gogo, a couple of thoughts...
You describe a pretty long history, several years at least, of shoulder problems. Also, the history includes biceps tendinitis and subacromial bursitis. These are classic early degenerative changes (arthritis) to the glenohumeral and AC joints.
You have had one of the best tests (MRI with contrast dye) to diagnose labral tear. It sounds like the results are inconclusive. Tech says labrum tear, surgeon disagrees.
The MRI with contrast dye is a more definitive test than an O'Brien's compression test. (If not, they would never do the MRI, because a clinical compression test is super cheap.) You DEFINITELY could get a positive compression test in an arthritic joint in the absense of a labrum tear.
If I was you, I'd find the best orthopedic surgeon I could find. I'd look for someone who specifically works with athletes, especially throwing athletes. You want someone who does surgery on professional or major college baseball pitchers.
You may be in line for a very unpleasant surgery called subacromial decompression. Rehab is long and painful. They'll tell you 3-4 months, but it will be 8-12 months before you max out.
But of course, that last paragraph is something to discuss with the surgeon.
Best non-surgical alternative is TONS of RC strengthening, and avoiding all activities that flare it up. And DO NOT THROW.
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boracus
Oct 14, 2008, 10:43 PM
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G-
In response to your labral tear question. I have a patient w/ a torn labrum (diagnosed by an orthopedic surgeon and MR) that is currenly climbing close to their maximum and has avoided surgery. My caviat here is exactly the point onceahardman brings up, it sounds like you've been dealing w/ a couple shoulder problems for quite some time and both involved inflammatory processes that may have created more glenohumeral damage. Since your MR was inconclusive it's hard to say how damaged your labrum really is. The cortisone may break the inflammatory cycle but certainly won't work in the long term. Ultimately what ended up working for my patient was using an herbal anti inflammatory such as Bromelain and/or Boswellia (since you can stay on either of these for extended periods of time w/ out inhibiting soft tissue repair or risking either you liver or kidneys.) and focusing on working the muscles of scapular stabilization. We actually ended up foregoing classic RTC exercises altogether (especially internal and external rotation exercises) because it only irritated the long head of the biceps and the labrum. I believe that the starting point was w/ seated one arm cable rows and scaption exercises. This being said they were working at a pretty low intensity, in the 12-20 repition range, for several weeks and ultimately were not able to start climbing regularly w/ out pain at any previous intensity until about 4 months. This may be quite a bit longer since it sounds like you've been climbing for quite some time and this person was a relatively new climber, so it may take longer before you feel that you can start to push your shoulder when climbing.
Good luck w/ the healing, BA
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onceahardman
Oct 14, 2008, 11:18 PM
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Hi boracus...
You have written some interesting things, both here and in the past. I heartily approve.
In this format, it's easy for one to say something that could be construed as a challenge or insult. That is not my intent.
I'd like to point out that "scaption exercises" really are a RC strengthening exercise. Directly targets supraspinatus, especially in the first 60 degrees of elevation. (I'm sure you know this, it's more for everybody else's benefit.)
Next, out of curiousity, what (if any) was the theoretical basis for the one arm seated cable rows? I'm glad they worked, I use them fairly often too, but specifically for reducing an impingement, I wonder what the theory is. General strengthening of scapular stabilizers?
Finally, regarding your specific recommendation of herbals. Is there any supporting research? (I understand that absense of evidence does not constitute evidence of absense). I wonder how an anti-inflammatory can do it's job without having an effect on the healing process. My understanding is that inflammation is the necessary first step in the proliferation of fibroblastic scar formation. I'd love to hear of an anti-inflammatory that had a different mechanism.
Again, not flaming, just intellectually curious. I like your posts, and respect your expertise.
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boracus
Oct 15, 2008, 3:12 AM
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OaHM-
Thanks for the interest, it's nice to get involved in a discussion involving climbing specific injuries. Plus, as I'm sure you understand, a lot of specifics can be left out in a general response whereas a set of specific questions makes you focus your thoughts.
Yes, your absolutely right, scaption exercises do target the supraspinatus... what was going on in my mind was more, removing the involvement of the subscapularis, Infraspinatus and Teres Minor muscles so as to eliminate rotation of the humerus. The pt I was working w/ was unable to perform any sort of rotation of the humerus against resistance initially w/ out pain.
In all honesty we started w/ the one arm rows and scaption somewhat through trial and error. I apologize if I don't answer your question here, I think you're putting the thought out there as to "why does strengthening scapular stabilizers help w/ a labral tear?" I don't have any literature to back this up, this is simply my observations from working w/ shoulder injuries and a lot of personal experimentation. I think that most climbers don't really understand that the glenohumeral joint is only one part of the entire shoulder complex. Most of the time when I'm starting out w/ a new pt w/ a shoulder injury I spend a lot of time explaining that the scapula can move independently of the glenohumeral joint. I believe that some traditional tactics in climbing (such as hanging from a relaxed shoulder to conserve energy) teach poor shoulder biomechanics which set a climber up for all manner of shoulder problems down the road, especially if the person climbs/trains several days a week. I believe that by not having enough strength in the scapular stabilizers cilmbers can't keep the scapula in the position it needs to be in when under heavier loads during intense climbing and there fore the climber substitues scapular strength w/ body positions that put more of the load on the long head of the biceps and triceps; since most climbers, if they do any sort of resistance training, usually focus on these muscle groups.
Secondly I'll also go on record as saying that I really do believe that beyond a certain point in each individuals climbing that resistance training of some kind is absolultely necessary, unless your just one of those genetic anomalies, to remaining injury free. I always am curious when I talk w/ climbers who say that they believe in training the antagonistic muscles to stay "balanced" and yet when I see them in the weight room they're focused on doing crunches and a few sets of triceps exercises at an intensity where they can get out 10 reps or more... and these are people that can climb into double digit V grades. So as a rule I tell clients that if you're training regularly and are pushing yourself to become a more physically powerful climber you should have at least one lifting session a week where the intensity of your antagonistic training matches the intensity of your more intense bouldering sessions. Sorry for the rant, training intensity or lack there of is a pet peeve of mine.
I have no links to provide you w/ to validate what I'm about to say. I have read some good research (reputable journals and well designed research methods) done on bromelain and boswellia as to it's effectiveness as both an analgesic and an anti-inflammatory. Some studies show bromelain to be as effective as Ibuprofen.
I must admit you've got me stumped on the effects of these two herbals when it comes to how they effect soft tissue healing. That is a damned good question and one that I'll have to do some looking into. I know that some literature shows that Ibuprofen can inhibit fibroblastic activity but I don't know if this is the case w/ the herbals. The only thing that I know the herbals do cause is a "blood thining" effect just like the rest of the anti inlfammatories. If you do come up w/ the physiologic mechanism for bromelain or boswellia please drop me an email I'd like to know.
Glad to have another climber w/ a medical background keeping the rest of us honest and improving the overall quality of info available to those injured climbers looking for answers.
cheers, BA
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gogo
Oct 15, 2008, 4:31 AM
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Interesting stuff. I've heard a few times now that a labral tear can be handled without surgery. If its the route that has to get taken, fine, as long as there is progress.
Had the first adjustment from the chiropractor yesterday, go back tomorrow to talk about proprioception exercises, and then I'm seeing the sports med on thursday to set up a new PT program. Been almost two weeks out from the cortisone shot, and just starting to feel like I have the same ROM as before the shot.
I'm surprised that arthritis is an option for what I could have done, as I'm pretty young - how many people get arthritis in their early 20s?
I've tried some supplements - glucosamine and chondroitin, which didn't have much effect. The one I recently got is called Cissus (quadrangularis), and seems to get a lot of great reviews from weightlifters, and seems fairly legit from scouring Pubmed (I still have access to my university's medical journals). Anyone tried it?
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onceahardman
Oct 15, 2008, 5:45 PM
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Hi boracus, thanks for the response.
In reply to: In all honesty we started w/ the one arm rows and scaption somewhat through trial and error. I apologize if I don't answer your question here, I think you're putting the thought out there as to "why does strengthening scapular stabilizers help w/ a labral tear?"
That's actually a really good answer. Sometimes we need to do some trial and error, to find some way the patient can move without pain.
I wonder, though, whether the patient improving over 4 months (I think that's what you originally said) can be attributed to the seated rows, or if the same healing would have happened anyway (idiopathic). No real way of knowing that. 4 months is a long time in PT. Most HMOs won't pay that long.
The theory behind RC strengthening for impingement is pretty simple. The tension vector of infraspinatus, especially, puts a downward force on the humeral head, keeping it away from the acromion.
When I've had patients too impinged to do ER/IR dynamically, I'll start them out with isometrics. Several times, within a single treatment session, I have improved symptoms enough so the patient could commence isokinetic training right away. ( I say I have done it for simplicity. The patient actually does all the work). Point is, (I think), you've got to get the cuff firing better if you want to reduce an impingement non-surgically.
Regarding herbals...I think we need to be careful. There is no reason to believe that because it's "herbal", "natural", "organic", or whatever, that it's SAFE, and EFFECTIVE. Remember, opium and cocaine are "natural", and "herbal" too.
Thanks, man, this has been cool. I'll talk this stuff as long as you want. Hopefully we can both become better clinicians as a result.
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marebear
Oct 16, 2008, 7:54 PM
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gogo wrote: I've tried some supplements - glucosamine and chondroitin, which didn't have much effect. The one I recently got is called Cissus (quadrangularis), and seems to get a lot of great reviews from weightlifters, and seems fairly legit from scouring Pubmed (I still have access to my university's medical journals). Anyone tried it?
Remember that Glucosamine/Chondroitin takes a long time to work and that you need to get and keep the levels up in your body before you will notice positive effects. The brand I use is Cosamin DS and was recommended to me by my Ortho after knee surgery.
If you do decide to seek another opinion and are willing to travel a little bit, I recommend Dr. Edwin Tingstad in Pullman, Washington. He is the team doc for WSU and one of the better shoulder surgeons in the country. He believes in avoiding invasive surgery when possible and did a dynamite job on my knees, as well as the shoulders and knees of several friends.
Good luck! I have shoulder tendonitis right now, it sucks.
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gogo
Oct 18, 2008, 5:28 PM
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So I saw a 2nd surgeon yesterday - doc up in Seattle who came highly recommended and works with a lot of elite athletes.
He went over the MRI report again with me and did a ton of clinical tests - and the shoulder proves to be confusing. Clinical tests have me with good range of motion and pretty strong, but pain in certain positions. The MRI shows possible labral fraying, but small enough that the surgeon didn't find it a concern (plus, no superior tear, where the pain is). Small tear in the supraspinatus, which could be the cause of the pain.
He thought that the diagnostic anesthetic giving me relief was a really good sign, but since the cortisone hasn't helped too much yet, that was not a great sign. Thinks it could be a lot of things, possibly just chronically irritated tissue that needs to be removed, or maybe a larger tear in the tendon or labrum that isn't showing up well, but that it isn't likely.
The plan we went over then is to really push myself with renewed PT and seeing the chiro for the next month. If there are no signs of improvement, then surgery would be a viable option.
He did show me one stretch that felt amazingly good, though, and has let me move my arm through the (formerly) most painful position without apprehension or pain, which is a great sign. So now its rotator cuff and scapular strengthening anew, and sleeper stretch in the am and pm - and a lot of positive thoughts. Can't hurt, right?
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gbogh
Oct 18, 2008, 9:30 PM
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I have been reading your thread and keeping up with your status and must say i can sympathize with you. i have a similar thread going a couple pages down tilted rotator cuff tear 2nd and 3rd opinions ....something to that matter. at any rate i went through a similar series of doc visits and MRI details and finally a doc told me to do the PT as you are going to be doing. Thing was that PT didn't prove to help at all and the pain was still there. when the doc went in, his main focus was to go in and scope the whole shoulder and then fix anything that needed fixing. turns out the MRI missed a pretty severe tear in the cuff and here i am 5 months later. i would go through with the PT and do exactly as they tell you. don't do any more and try not to use the arm at all (harder than it seems i know). that will give you a really good idea if the PT is working or not when your month is up.
i can't recall if you mentioned pain at night at all? if you wake up at all during the night to a throbbing pain that can be symptomatic of a cuff tear as well....
at any rate, i wish you the best with your recovery etc....believe me i learned my lesson and will do my best to keep my shoulders strong once i am able to start back into climbing etc...
John
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gogo
Oct 19, 2008, 3:08 AM
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Thanks, sounds like this happens more than I thought.
Went through a full range of rehab exercises today, the only new ones I've added were seated cable rows to strengthen the scapular retractors.
The shoulder is sore, but the specific spot at the front of the shouder than hurt when I raised my arm (thumb down) has felt better after doing the sleeper stretch seriously. Hopefully it all helps; I'm young and would like my body to be able to heal itself well.
At the same time, if it turns out that surgery is the only option, then I want it done ASAP so I can start recovering and get back to climbing. I would love to climb again in 2008 but I'll take spring/summer 09 if that's what it takes.
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zirkel
Oct 20, 2008, 4:27 PM
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gogo:
I'm just coming back (strong!) after a 90% tear/repair of my supraspinatus and related subacromial decompression (Feb. 2007) and followup bicep tenodesis (Nov. 2007), not to mention two shoulder arthrograms/MRI's.
Thanks to the work of an outstanding shoulder specialist (see below), I was climbing again in March 2008 -- also with the help of LOTS of icing, stretching/yoga, arnica gel, ibuprofen and PT.
Expect, at least, a FULL year to regain your previous level of climbing strength and flexibility.
http://www.rcmclinic.com/doctors/metcalf.php
(his partner recently did Tiger Wood's knee)
Another great resource:
http://www.shoulder1.com/forum/index.cfm?cas_checked=1&userid=0
Good luck!
Dav
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gogo
Nov 3, 2008, 2:05 AM
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Two weeks into the really serious rehabbing to decide whether or not I'll need surgery - seeing the chiro still to work on my neck and back.
Lots of full-can, scapular pinches (seated rows), serratus anterior stuff (forward punch), internal and external rotation, and stretching.
Shoulder getting stronger, but still flares up way too easily to trust it to try and climb on. But on the plus side, the specific spot where I would get pain on the front of my shoulder isn't really there anymore, so I'm hopeful.
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gogo
Nov 19, 2008, 11:46 PM
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Ok, figure I'd toss an update up if anyone is interested/see what opinions I can gather.
Finished the six weeks of PT until the cortisone was out of the system before seeing the surgeon again. Did lots of stretching and the PT exercises exactly as directed. The painful spot on the front of my shoulder is basically gone, can only feel it at the very maximum of my overhead reach. Got major ROM, still feels weird with some motions, but less crepitus for sure.
Wasn't that happy with the surgeon I saw yesterday; waited for an hour past when my appt started and then got a quick, five minute check before he suggested doing . . . surgery if I felt like it. I think if I need surgery, I'm going to the other surgeon I saw.
Either way, I got to test it out climbing last night, just easy traversing and a couple of 5.7s. The shoulder felt ok in just about all positions, no twinges of pain, just general tightness. But dear god it felt good to be moving on the wall; hands shaking with happy. Makes me more convicted to do whatever it takes, PT or surgery, to get back to this life.
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lithiummetalman
Nov 20, 2008, 5:12 AM
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I too had Subacromial bursitis and a partial labrum tear about 2 1/2 years ago.
Like you and Zirkel I went to see a PT specialist, his methods for rehab, albeit a bit unusual worked considerably well and to this day have full ROM and rarely have any flare ups/
Recommendations PT suggested was to use capscasin or camphor instead of ibuprofen to help with the recovery process, as well as a weekly deep tissue massage to help "reset" the muscles (is that right?).
As in terms of rehab exercises he gave me a few exercises in this progression:
1. A pose where you try to raise your hands as high up as possible (we did this progressively), look up and try to stretch to the sky while imagining one was trying to stretch their spine to the sky as well. (sounds confusing)
2. Rising dog, but done in a progressive way until I could pull one off fully without pain or hinderance the next step was to start in downward dog position, but on my knees and go into the rising dog position, kinda like a hindu push-up, and then reverse it.
3. He also gave me a few other spine stretches, though seemingly odd, it really helped my shoulder out
4. The last one is probably the most unusual exercise, but just as helpful: Qigong exercises, the movements themselves seemed to go through a whole range of shoulder movements.
5. Not sure if this helped, but I quit climbing for about 4 months after the injury and interview with the PT (this was after blowing out the other shoulder, you'd think I learn), used this time to practice PT's recommendations.
Best of luck to your recovery, as Zirkel mentioned it takes a year or more to heal!
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Ains
Nov 20, 2008, 6:04 AM
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so what movement or action causes you the most shoulder pain and where again? Does it hurt at rest, when elevating it? Sounds like you've been to everyone and that you have good RC strength. What about scapular position/mobility? What has helped the most? Either you are special or there is something everyone is missing.
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gogo
Nov 20, 2008, 4:31 PM
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lithiummetalman , did you have your labrum repaired via surgery or did you just go through dedicated PT? Keep hearing mixed results; some people seem to get over it with PT, and some say surgery is the absolute only way.
The spine stretching thing I think helps out with me as well; its one of the big things the chiropractor has me working on. Tried the qigong exercises as well, but this was also when my shoulder was way more flared up and I had to back off it.
Forward and overhead pushing motions are the most sensitive; much more overhead that forward (but push-ups are still out). Forward chess press with a plus (For serratus anterior) with a theraband really seemed to help, as did the full can exercise. Scapular stabilizing exercises (cable rows) seem to help, but my upper left back flares up sometimes.
No longer really hurts at rest (just a lot of tension in the trapezius and upper back), feel minimal discomfort reaching overhead, a little pain at the extreme of overhead motion. Arm overhead and reaching behind me feels uncomfortable.
The biggest plus for me so far has been that when it really hurt, pulling up (as in the most basic climbing motion) hurt specifically in the front of my shoulder everytime I did it; when I tested it out two days ago, there was no specific painful spots, just felt uncomfortable.
The new PT I saw yesterday wants to start working more scapular stabilization, more internal/external rotation, and eccentric lat work - basically thinks I have too much mobility in my shoulders and need more stability.
The opinions and viewpoints are much appreciated; if I'm going to opt for surgery, I want to know that I've exhausted everything else possible, but I don't want to keep trying at something that isn't working.
thanks
mike
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gogo
Dec 2, 2008, 1:48 AM
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Goddamn Shoulders.
So the PT was going really well all of last week, starting to get a lot of new motions and exercises in, and I even got a couple of sessions in traversing.
However, the last session left me feeling pain in the joint when I would try for external rotation, and it took about 4-5 days to clear up - still cant do external rotation with nearly as much weight as a week ago.
Wondering if it is just a small flare up, or if I'm pointlessly trying at getting around something that needs surgical intervention. . .
just my venting.
mike
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gogo
Dec 3, 2008, 9:04 PM
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Posts: 198
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Well people, thanks for all the advice and letting me rant about my shoulder on here.
Set a surgery date for next thursday - started regressing in PT and figure that after about a year of problems with it, there is probably something structurally wrong inside.
Scheduled for a decompression and potential debridement/repair. I'll update how I'm doing at various points for anyone else thinking of getting this done.
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