Shoulder rehab in the Denver area

Hey GB community,

I have developed impingement in my shoulder and am looking for a physical therapist in the Denver area who is at least well-versed in gymnastics training, and at best is a participant in the seminars, Forums, and closely familiar with BtGB. Does anyone have any referrals?

The background: in June/July 2010 I started a static-strength training routine based on the progressions outlined in BtGB. I started very weak -- 15s frog, 2-3s tuck front/back lever, 15s intro L-sit on PB, 10s wall handstands, 3x3 piked HeSPU, 3x3 ring pushups (1st progression). In December 2010 I took a break due to "shoulder pain," which I hoped/expected to go away with rest. I had achieved 10s adv. frog, 15s tuck front lever, 20s tuck back lever, 12s XR L-sit, 60s wall handstands, 5x5 piked HeSPU, 5x3 bulgarian pushups on XR. I have since come to realize that my shoulder pain will not go away with rest, and am of the opinion that I've developed an impingement brought on by overtraining and by imbalanced training, exacerbated by poor posture at my day job (I drive a desk for 9-12 hours per day). I have been to an orthopaedic doc (hence the diagnosis of "impingement") and a PT, but the PT was completely unfamiliar with BtGB specifically and gymnastics in general, and I did not realize much recovery. Then I moved and got married and have not well-prioritized rehabilitation (I've done some work on and off, but inconsistently, and never without pain). My life has settled into more of a routine, and I really, really want to get back into structured BtGB-based strength training. I *love* the lasting strength gains that I saw from the BtGB progressions that I cannot say I realized from barbell strength training.

So: I am looking for a physical therapist / orthopaedic doc who understands the BtGB progressions and can guide me in the correct ways to strengthen my shoulder and relieve the impingement. I need a PT/orthopaedic who can identify the kind of impingement ("impingement" is a very loosely-applied term, there seem to be 2-dozen different tissues that can be impinged upon in the shoulder girdle, and correct recovery depends on what's getting pinched and how), and can speak to me in precise, technical terms (I am an engineer, and I like to understand the cause & effect).

I am reaching out to the community before I just go to a sports therapist and "get the best I can find." Thanks in advance!

wam

My recommendation is to contact GB forum member orenchCRUSH. He is in the Denver area, has attended mulitple GB seminars and is a very good trainer with a solid grasp of GB fundamentals.

Yours in Fitness,

Coach Sommer

Coach Sommer said:

My recommendation is to contact GB forum member orenchCRUSH. He is in the Denver area, has attended mulitple GB seminars and is a very good trainer with a solid grasp of GB fundamentals.

Yours in Fitness,

Coach Sommer

Wow, thanks for the immediate response coach, much appreciated!

If I were you instead of paying somebody to fix you up, educate yourself and fix yourself. I too have shoulder issues because of bad posture and too much emphasis on protacted scapula strength elements and not balancing my upperbody. I don't need to pay someone to do the rehab that I can do myself with a bit of reading. You will make a much greater investment in yourself by doing that IMO. Buy Triggerpoint therapy workbook and Pain Free. great tools to get started!

mrnielsjoergensen said:

If I were you instead of paying somebody to fix you up, educate yourself and fix yourself. I too have shoulder issues because of bad posture and too much emphasis on protacted scapula strength elements and not balancing my upperbody. I don't need to pay someone to do the rehab that I can do myself with a bit of reading. You will make a much greater investment in yourself by doing that IMO. Buy Triggerpoint therapy workbook and Pain Free. great tools to get started!

I'm way past the point of "getting started." Thank you for the book suggestions.

I actually tried a chiropractor after years of chronic shoulder pain (mostly due to breaking my collar bone). This keeps me going without pain. This could be worth a try if you haven't tried this type of thing. I was a sceptic and remain so regarding chiropractic, but I know that this is the only thing that has worked for me for my issue.

edna said:

I actually tried a chiropractor after years of chronic shoulder pain (mostly due to breaking my collar bone). This keeps me going without pain. This could be worth a try if you haven't tried this type of thing. I was a sceptic and remain so regarding chiropractic, but I know that this is the only thing that has worked for me for my issue.

I've considered it... but I'm also a skeptic, so I'm not desperate enough yet, haha. I'm pretty sure the issue is muscular-skeletal, as I can hear and feel things clicking internally if I move in particular ways.

Artemev's gym should be nearby. Call them up and see if they recommend anybody. 5280 is what's its called. Maybe call up tom Forster down in Co springs or the Olympic training center.

Def try to hook up with Orench.

Shoulder "impingement" is a loose descriptor, in my clinical experience, and covers pain from imbalances between internal–external rotator cuff muscles through capsular pain, to long head of biceps impingement, to impingement of the supraspinatus tendon (or impingement of the nerve that innervates supraspinatus itself) by the shoulder girdle. Each are different causes with different solutions.

Having said that, the major cause of shoulder pain are a combination of factors, which given the OP's occupation, seem a likely starting place. In general, tight hip flexors, in combination with an increased kyphosis of the thoracic spine and a forward holding of the head, create an unfortunate alignment problem for the shoulder girdle, which 'floats' on the rib cage via the shoulder blade, and the whole of which (shoulder girdle and arm) which pivots around only the sterno-clavicular joint, when considered from the side.

In the scenario just described (increased kyphosis), the shoulder girdle is anteriorly rotated, and this creates potential biomechanical inefficiencies when attempting the BtGB moves the OP described: the long head of biceps tendon is exposed to more stress than when the shoulder is in the optimal alignment, and if the external rotator cuff pair (teres minor and infraspinatus) are weaker than their opposites, then the humerus is pulled anteriorly in the joint capsule when pushing or pulling—and pain can be the result (the joint capsule is well innervated, and will signal pain if stretched). This alignment also guarantees that holding a well-aligned handstand will be difficult, too.

My suggestion is to gently stretch supraspinatus; see here:

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Then use the following partner exercise to open the chest, stretch biceps, and realign the shoulder gordle; see here:

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And work on stretching the hip flexors; see here:

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Finally, and I do not have a clip on this, try stretching the whole of the thoracic spine backwards, by lying backwards over a curved support.

Correction; apparently I do; see here:

If you do find a practitioner, ask him/her to test comparative internal/external rotator cuff strength (make sure they inhibit the middle deltoid during the ext. RC test; this is a common problem that gives the impression of much greater strength in these small muscles than is actually there!); and if, as is likely, the exteral RC muscles are weaker, then I can suggest some practical strengthening exercises in a follow-up post.

The take-home message is that pain is the indicator that your biomechanics are not sound; the task is to find out where the deficits are, and redress. HTH kl

Thankyou for taking the time to post this here Mr. Laughlin. Very helpful.

Coach & Kit

Thank you so much for allowing gymnastics coaches and strength enthusiasts to have access to such amazing and helpful information! I just spent about 3 hours going through all of Kits videos and site material and the relevance to gymnastics is excellent! Just wanted to speak my level appreciation as a young and striving gym coach and former gymnast this information would have saved me many years of pain and misery had my coaches took the time to be more knowlegable!

Thanks Again

Jacob

Kit, thank you so much for your response. This is exactly the sort of help and guidance I am looking for. I have indeed noticed tightness in my hip flexors, but I never thought to associate that with my shoulder pain. I have also tried strengthening the supraspinatus muscle (thinking that the supraspinatus tendon was out of place, and this was the cause of the impingement). It seemed I realized some progress for a bit, then plateau'd/stagnated (this also happened with the stretches that Slizzardman has on his youtube page). I will work the stretches you posted and keep you in the loop regarding the results.

What are your thoughts on these exercises: http://www.physioshare.com/upload/uploa ... tation.ppt ? I have been working them for about 4 weeks now. I feel some tightness at the end of the ROM on the "Field Goal" exercises, and I feel like the "Plus" (which I do on rings b/c I do not have Dynadiscs) and "Subscapularis Pull" aggravates the pain (with the aggravation from the subscapularis pull coming only at the end of a set of 20-30). I feel like the "Modified Empty Can 1" and the 2nd & 3rd slides of the "Standing Three-Way" engage muscles very positively. The best thing I took from the last PT I saw was that when I raised my arms I would shrug my problem-shoulder (this was something i had never noticed myself -- couldn't feel it, and didn't know to look for it -- and the PT said it was my body compensating), and in those two exercises I have to actively concentrate to keep from shrugging. When I do, I can feel the stabilizing muscles in my lower back (which I understand are quite small) engaging. It's a good feeling, one of progress. Unfortunately it doesn't seem to translate into "fixing the impingement as a whole."

Thanks for that writeup Kit, very helpful!

wamarler wrote:

I have indeed noticed tightness in my hip flexors, but I never thought to associate that with my shoulder pain.

This is a most significant causal relationship: even if you are immensely strong in the core, when the body is in the relaxed load-bearing position (standing or sitting), the abdominal muscles are relaxed—and if the hip flexors are tight (or even if there's simply a pattern of holding at a particular length-tension relationship), the pelvis will be tilted anteriorly and then a kyphosis is the response (basically, to keep the head over the centre of gravity).

Another note: if, when someone tests you, the external rotator cuff muscles are weaker than the internal one (subscapularis), then they can be strengthened by using bands or cables with resistance. I cannot recall if I made a video on this (and the internet is too slow here to check right now) but key to effective strengthening is switching off supraspinatus and middle deltoid, by putting a ball or similar between the elbow of the working arm and the waist—and inhibiting these muscles by using pec. major and latissimus dorsi to pull the ball in to the waist. This action reciprocally inhibits the former muscles—and that means when you externally rotate the arm against the resistance, only the target muscles are activated, and strengthened.

I will look through the videos when I get a better connection; and if I do not have one I will try to shoot one over the next few weeks.

Apart from trauma, almost all shoulder pain results from one part of the complex being stressed more than another, simply because there is either insufficient stabilisation available to the body, or there is insufficient range of movement to get optimum alignment, which is essential for sound biomechanics. The major fraction of shoulder flexion (getting the arm in line with the spine, above the head) comes from thoracic extension, and not from the joint itself. Using the joint to lever this ROM almost always results in shoulder pain, which is why I recommend passive thoracic extension. There's more, but this will get you started.

To the OP: please report back once your external rotator strength has been assessed.

And a relevant aside here is that, in my experience, only gymnasts and rock climbers demonstrate equal strength in internal and external rotation—no accident!

kit laughlin said:

This is a most significant causal relationship: even if you are immensely strong in the core, when the body is in the relaxed load-bearing position (standing or sitting), the abdominal muscles are relaxed—and if the hip flexors are tight (or even if there's simply a pattern of holding at a particular length-tension relationship), the pelvis will be tilted anteriorly and then a kyphosis is the response (basically, to keep the head over the centre of gravity).

Interesting that you find it such a major cause!

Have you got any thoughts on how much specific work is needed to re-educate "a pattern of holding at a particular length-tension relationship"? (in cases where the subject is a typical desk rider 6-12 hours per day)

Regarding the internal/external strength ratio of the cuff, do you really find a 1:1 relationship is prefered? I thought the typical recommendation was more like 1:,75

interesting post. I would be very surprised tho if you would find anyone with equal shoulder IR/ER strength ratios esp in gymnasts. I mean Pec Major and Lat dorsi are powerful internal rotators of the shoulder, and esp in gymnasts who are so strong in these two muscles there is no chance suprispinatus, infraspinatus and teres minor are going to be anywhere near as strong, not even including subscap.

Another Point, I wouldn't say tight hip flexors equates to kyphosis of the thoracic spine. Tight hip flexors most definitely equate to an increased lordosis in the lumbar spine, but that doesn't mean a kyphosis is a compensation. The first culprits for kyphosis are normally tight pec major, pec minor, lats. That being said as well many people have a naturally kyphotic spinal shape without any actual pathology creating it.

In short I guess what I'm saying is as much as advice over the internet is great and there are some good points here, find a skilled therapist.

Dr Durden wrote:

(part 1) Have you got any thoughts on how much specific work is needed to re-educate "a pattern of holding at a particular length-tension relationship"? (in cases where the subject is a typical desk rider 6-12 hours per day)

Re. part 1: much less than you might think, and I believe this is because when we are 're-educating' this relationship in someone's body, they are paying attention to the new sensations; the redistribution of the body's weight through the proprioceptors in the feet especially; and myriad other sensations (and it is sensations that remake the somatosensory cortex's 'map' which is what creates the length–tension relationship in the first place: when you reach the edge of the 'map', protective tension is created). The length–tension relationships that I am describing as potentially dysfunctional are acquired while 'asleep' (that is, they are unconscious habits aqquired without conscious choice. The can be changed in weeks/months. Finally on this point, I recommend doing your indicated exercises much less than most people recommend (with this caveat: the more 'dysfunctional' the patter you want to change, the less often you practise the remedial exercises, but with weekly intervals as the minimum, and twice a week as a maximum.

There's more, though: the superficial fascia, in particular, needs to be freed (this can be done by particular approaches to stretching as well as by manual therapy, and sometimes both at the same time), as the latest research shows that all nerve endings are found therein. In the partner stick stretch I cite above, someone's shoulder alignment (in terms of where they 'hold' their shoulders can be changed in a a single iteration. Whether this becomes the new normal depends on what the person then does subsequently: the system is alive and the new 'trajectory' will be maintained if the owner experiences benefits!

(part 2) Regarding the internal/external strength ratio of the cuff, do you really find a 1:1 relationship is prefered? I thought the typical recommendation was more like 1:,75

Re. part 2: Yes, I do. In my experience with elite athletes who rely on critical shoulder strength (like cricket bowlers, baseball pitchers, and gymnasts), the 1:1 ratio is much to be preferred. My recommendation is made after testing thousands of people (and finding that the norm is 1:0.5-0.6 in the majority), and comparing that ratio with elite athletes who require exceptional shoulder strength AND who have zero shoulder problems, and who, on testing, show 1:1 or thereabouts. YMMV, of course.

Typical recommendations yield typical results, in my experience. I have never found norms (in the statistical sense) particularly helpful but always make my recommendations based on what I find in a left–right comparison of key functions in the person in front of me. Moreover, in the case of one famous athlete, until he was able to do external rotator cuff exercises in sets of five reps with 30Kg (~65lbs?) in strict form on a cable machine (which is a load way higher than what's recommended in the physical therapy literature), he reported that his shoulders just did not feel 'right'. Now, I know there is nothing 'scientific' about feeling 'right', but anyone who has had a shoulder problem can relate—and until you can trust a part that has failed you in the past, the brain will always have reservations about using full power in the movement that hurt it, and movement patterns can be compromised by this fear.

There's more, of course, but given this context, I hope that's enough for now.

Demus wrote:

I would be very surprised tho if you would find anyone with equal shoulder IR/ER strength ratios esp in gymnasts. I mean Pec Major and Lat dorsi are powerful internal rotators of the shoulder, and esp in gymnasts who are so strong in these two muscles there is no chance suprispinatus, infraspinatus and teres minor are going to be anywhere near as strong, not even including subscap.

I do understand this point. We use the reciprocal inhibition reflex to deactivate the potential contribution of the deltoid to the external rotator cuff pair, and we use a second therapist to isolate the shoulder girdle so that subscapularis's contribution to internal rotation can be assessed. The testing I am talking about, if done the way I describe, can reasonably accurately compare just the strength of these small muscles.

And I agree about finding a good therapist, if you can.

Demus wrote:

I wouldn't say tight hip flexors equates to kyphosis of the thoracic spine. Tight hip flexors most definitely equate to an increased lordosis in the lumbar spine, but that doesn't mean a kyphosis is a compensation. The first culprits for kyphosis are normally tight pec major, pec minor, lats. That being said as well many people have a naturally kyphotic spinal shape without any actual pathology creating it.

I did not say "tight hip flexors equates to kyphosis of the thoracic spine", I believe, and I did not say kyphosis was a "pathology". It is a more general relationship, and I was talking about the OP's situation (doing gymnastic training; desk-bound, and with a shoulder impingement problem). The general point here is that, while kyphoses are common in gymnasts at rest, all have the mobility and flexibility to achieve biomechanically optimal alignment when needed. Most non-athletes do not have this capacity, and the exercises I recommend can achieve this, in time.

If pressed to be precise, I do not say that tight pec. major, pec. minor, and lats are the cause of kyphosis, either, but are usually found in conjunction with this shape, in gymnasts in particular. The training helps create these patterns; and they are not a problem in themselves, necessarily. My remarks were addressed to the OP; hth, kl

Dear Mr Kit Laughlin,

You seem like you know your stuff. I'd like to visit you, but judging from your accent, you're nowhere near Chicago. Please move here.

kit laughlin said:

Demus wrote:

I wouldn't say tight hip flexors equates to kyphosis of the thoracic spine. Tight hip flexors most definitely equate to an increased lordosis in the lumbar spine, but that doesn't mean a kyphosis is a compensation. The first culprits for kyphosis are normally tight pec major, pec minor, lats. That being said as well many people have a naturally kyphotic spinal shape without any actual pathology creating it.

I did not say "tight hip flexors equates to kyphosis of the thoracic spine", I believe, and I did not say kyphosis was a "pathology". It is a more general relationship, and I was talking about the OP's situation (doing gymnastic training; desk-bound, and with a shoulder impingement problem). The general point here is that, while kyphoses are common in gymnasts at rest, all have the mobility and flexibility to achieve biomechanically optimal alignment when needed. Most non-athletes do not have this capacity, and the exercises I recommend can achieve this, in time.

If pressed to be precise, I do not say that tight pec. major, pec. minor, and lats are the cause of kyphosis, either, but are usually found in conjunction with this shape, in gymnasts in particular. The training helps create these patterns; and they are not a problem in themselves, necessarily. My remarks were addressed to the OP; hth, kl

Kit is right. Excessive lordotic curvature necessitates a kyphotic posture in the t-spine regardless of why there is excess lumbar curvature. Hip flexor tension (regardless of reason, and particularly the iliopsoas area) is a very common cause for this. There are multiple positions, from typical hunchback kyphosis to swayback posture (which often looks straight or nonkyphotic at first but upon closer inspection is often just as curved as the hunchback posture) and not all have a forward shoulder posture associated.

It's certainly possible for one to lead to the other regardless of which one comes first, but Kit has really covered this quite nicely.

It is important to distinguish between a few things:

1a) Asymptomatic pathology and 1b) Symptomatic pathology

2a) The ability to assume a kyphotic position when required (regardless of time in position) and 2b) Staying kyphotic for long periods of time when not required by specific sport demands.

3) The ability to extend the thoracic spine 20-30 degrees beyond straight without help.

Losing #3 usually happens as a result of #2b. Utilizing #3 regularly protects 2a from becoming 2b. 2b leads to either 1a or 1b. 1a often becomes 1b over time and this transition is directly dependent to how unbalanced the musculature and movements become and how often, for how long and how vigorously/intensely the movements are used.

Demus, If you or anyone else are kyphotic outside of exercises/sports that require such posture and and do not have pain, you are #1a. The biggest risk factor will be losing #3. The shoulder forward posture and head forward posture that are often associated with this are also risk factors, but the inability to utilize a full anatomical ROM is the real indication of what your risk factors are because this will determine how your joints are forced to work even under relatively low [physical] stress conditions (every day life) and that is where most time is spent for nearly everyone.

Do not make the mistake of thinking something is not pathological simply because it causes no symptoms. Many of us carry cold viruses without showing symptoms. That doesn't mean we don't have the cold virus, it just means our body isn't showing any symptoms. You put us under stress and malnourish us, and NOW we are showing symptoms. We often didn't pick up a new virus, we just put enough stress on the system to allow symptoms to develop (in this case due to immunosuppression).

As a different example, you can have a 40% blockage of a coronary artery without any symptoms at all. No high blood pressure, no ischemia, no nothing. You still have cardiovascular disease. You are still in a pathological state.

I don't want to write much more in this post, it's big enough. I hope this make sense.

Thanks again to Kit for such an awesome post!

Hey all,

Thanks for all this great feedback. There is a wealth of fantastic knowledge amongst you all, and I'm glad I could bring you together to talk. I also like how every now and then someone writes "but getting back to the OP ..." . Consistently people have said "find a good therapist" which was the point of my first post! I am looking. Sadly Orench hasn't replied to my PM (do any of you know him personally, and can give him a nudge to check his inbox?); next stop is 5280gymnastics.

thanks,

wam

Orench hasn't replied to my PM (do any of you know him personally, and can give him a nudge to check his inbox?)

I dropped Orench a note for you. He is usually very good about getting right back, so perhaps he is out of town just now.

Yours in Fitness,

Coach Sommer

Coach Sommer said:

I dropped Orench a note for you. He is usually very good about getting right back, so perhaps he is out of town just now.

Thanks coach, very much appreciated.

@ phrak: I live in Australia, but come to the U.S. once or twice a year, both to attend workshops (like Coach Sommer's, this year in AZ) and to present my own work.

@ Joshua: thank you for your kind remarks. If there's interest, I will expand on the rotator cuff strengthening aspects, too.