Dr Houser's Shoulder Rehabilatation Thread

[dinoiii]

Dr. Houser's Shoulder Rehabilitation

* Author's Note: reiteration of my signature - the information contained herein is NOT meant to replace the quality advice an EXAMINING physician could offer. It does NOT necessarily represent the views of MAN Sports, Inc yet will be a follow-through of my own road back. You will likely find a LOT of information to aid in adequate patient/physician rapport and with that I wish the best with one of the most frequent injuries, by far, seen in the gym.



Introduction/History

In early 2006, my max flat bench press was 450 x 3 reps (shared it with the guys over on the DA forum when it happened).

In April 2006, however, with 315 on the bar, I caught the left peg coming down and my "spotter" exclaimed "Wow, that was just like slow motion man" as the 315 pounds comes down on my right shoulder. Uhhh mental note: NEVER incorporate a guy to help that is less than 2/3 of the weight you are attempting to lift. So, I offered what I thought be reasonable retort at the time "Yeah cool deal numb nuts...don't let it happen again." Threw up another set and felt fine...

Stepped up to the incline - a simple 135 pounder to start, took it down to my chest and OH SH*T...low and behold, I asked my "new spotter" to pick up the weight.



Physical Limitations

As I have mentioned in other forums, I never could appreciate this fully, even with having clients with similar experience over the course of the last 6+ years...well, of course until last year.

The lifts impeded by my injury that piss me off the most:

1. Bench (flat and incline - often I can get the decline based on angle with less pain, perhaps this is something you can try if yours was a true anterior delt injury)

2. Weighted Dips (I fight through the pain most of all on these and have lifted up to 3 plates on this, but really am upset in the aftermath )

3. Pull Ups (this is the least of concern - happens like every 4th workout or so, where it will be agonizing so much that I need to get an answer Mon of a more definitive light because they are becoming more frequent here then they used to).



Imaging

MRI at the time showed inflammation to the anterior delt (perhaps a tad bursitis), nothing else but could have been the start of a minor compression syndrome setting in the supraspinatis tendon, but the imaging was unclear in this regard, or perhaps too soon.

Sweet - here I was almost a year later with growing pain. Of course, the doctor at the time offered me the choice of cortisone shot, and thinking ahead to the potential of what a cortisone shot could offer, I opted out. He also offered me the option to lay off the training, which I said in the current state of rehabilitation research, rehab goes the route of low-carb diets - "MEAT is superior to RICE" these days, namely with the potential for impingement syndromes. He had absolutely no idea what the hell I meant, but alas I digress...

Well, you know what they say - "Doctors make the WORST patients!"

Oh, and by the way
MEAT: "Movement / Exercise / Analgesia / Treatments"
RICE: "Rest / Ice / Compression / Elevation"


Follow-Up Imaging

2/12/07: MRI - Significant Tendonitis of the Supraspinatus tendon and Bursitis of the subacromial region, cannot rule out a possible Stage I impingement syndrome.

My offerings were virtually the same as before w/ inclusion of PT. Again, I have opted out...but plan to share with you below what happens in my own self-constructed rehab program. Stay tuned...


D_

[dinoiii]

Injury Chalk Talk

As bodybuilders, we are fortunate to be continual students of anatomy and I am hoping with this discussion to offer a look into what the MRI described above.

When we take a moment to recall what the rotator cuff is, we understand it is the collective group of four muscles I so fondly remember using the acronym SITS to recall in medical school anatomy classes of the shoulder girdle. Each letter represents the first letter of one of the muscles involved in the group we hear so much about.

Supraspinatus
Infraspinatus
Teres minor
Subscapularis

My MRI showed "significant tendonitis of the supraspinatus tendon" and "subacromial bursitis." You are likely asking yourself, what the hell does that mean Dana - well ... anytime in medicine you hear the suffix "itis" - it merely means inflammation. Think hepatitis (liver inflammation/swelling), pnemonitis (lung parenchyma inflammation/swelling), tendonitis (tendon inflammation/swelling), and so on. Of course, some offer further complexity in the naming system - but it is well beyond the scope of this piece - plus if I were to offer all of our secret doctor "code language," you'd have no longer much rationale to pay us what you do! :wink:



Photo #1



In this anterior view of the shoulder, you can see most prominently the relationship of the supraspinatus tendon (recall: tendon is attachment of a muscle to bone, ligament is attachment of a bone to bone)...coming from the back where the supraspinatus muscle sits in the clavicle and the essential subacromial bursa (its kind of a fluid-filled sac of sorts that exists between various tendon structures and allows for lubrication of the joint - obviously when it becomes inflammed, using our knowledge from before - it is dubbed "bursitis" and it goes hand in hand with supraspinitus tendonitis...I am glad to see I fit the prototype).



Photo #2



Here, I have offered you a lateral view to simply get an idea in 3D how this whole thing would tend to come together. Some muscles depicted have been cut to show alternative structures (this is status quo when anatomy texts are concerned and you would otherwise suffer rather limited view).



Photo #3



The posterior view is likely the best view of all the rotator cuff muscles (exception: subscapularis), but NOT necessarily a great view of afflicted area. You can see the area of involvement still, however both the spinous process of the clavicle (which denotes the take off of the supraspinatus muscle above and infraspinatus muscle below) and acromium process impede realistic view.



What is Impingement Syndrome?

Recall that my MRI also suggested that you could not rule out possible Stage I Impingement Syndrome. This "cannot rule out" nomenclature is sort of standard on many imaging study reports and isn't necessarily ominous to me or anything. It likely sounds a lot worse than it is.

Impingement Syndrome, which is sometimes called Swimmer's shoulder or Thrower's Shoulder, is caused by the tendons of the rotator cuff (as we have described above) becoming irritated and inflamed as they pass through a narrow bony space called the Subacromial Space (depicted above, the area that houses the subacromial bursa) so called because it is under the arch of the acromion.

This can lead to thickening of the tendon which may cause further problems because there is very little free space, so as the tendons become larger, they are impinged further by the structures of the shoulder joint and the muscles themselves.

Stage I typically indicates that there is some sort of fluid collection that accompanies this inflammation and it usually either is a spill over from some edematous notion or hemorrhage as the alternative (hehe, I hope for the former).



So, this was the basic anatomy lesson - I felt like I was back in front of the classroom setting (I taugh anatomy and physiology classes back in 2000). Next on the slate will be the beginning of our discussion of the actual pharmacobehavioral items I will include in a self-devised rehab program.

Thanks for keeping posted. Stay tuned...


D_

[dinoiii]

I am going to offer a look into my initial development of the treatment protocol I use.

First, a slight digression into how this potentially developed:
Supraspinatus tendonitis is often attributed to impingement, which is seldom mechanical in athletes. Rotator cuff tendonitis in this population may be related to subtle instability and therefore may be secondary to such factors as eccentric overload, muscle imbalance, and glenohumeral instability or labral lesions. This has led to the concept of secondary impingement, which is defined as rotator cuff impingement that occurs secondary to a functional decrease in the supraspinatus outlet space due to underlying instability of the glenohumeral joint.

Secondary impingement may be the most common cause in young athletes who use overhead motions and who frequently place repetitive large stresses on the static and dynamic glenohumeral stabilizers, resulting in microtrauma and attenuation of the glenohumeral ligamentous structures and leading to subclinical glenohumeral instability. Such instability places increased stress on the dynamic stabilizers of the glenohumeral joint, including the rotator cuff tendon. These increased demands may lead to rotator cuff pathology such as partial tearing or tendonitis, and, as the rotator cuff muscles fatigue, the humeral head translates anteriorly and superiorly, impinging on the coracoacromial arch, which leads to rotator cuff inflammation. In these patients, treatment should be directed at the underlying instability.

The importance of this background insight into the pathologic process cannot be underscored as it will likely dictate exercise selection, etc... en route to the completely-healed state (or at least I hope so!).



As I noted above, MEAT is superior to RICE and such remains the case here.



Essential Goals of Said Acronym:
Movement: You will not let the shoulder area get stiff
Exercise: Carefully designed exercises will be employed throughout the entire duration of the program
Analgesics: These will be used as needed, however, I can withstand much pain to avoid any potential muscle atrophy, et al.
Treatments: You will see this as likely different than many sports medicine evaluations as I am avoiding the touted therapeutic corticosteroid injections.



So, the goals have been set in place. Tomorrow, I will describe each of these in turn...

Stay tuned...

D_

[dinoiii]

Out of the MEAT acronym, I will address the agents of choice in Analgesics and Treatment categories as they are already established for the most part. The complete movements and exercises will be added in a subsequent entry.



Pharmaceutical Analgesics

Ibuprofen PRN (as needed); as suggested above I am going to attempt to avoid this, by shifting most of my concern to the following Supplementary "Treatments" protocol below.

Why am I trying to avoid Ibuprofen or other Non-steroidal anti-inflammatory drugs (NSAIDs)? Well, while NSAIDs do ease pain and decrease inflammation, their action may inhibit the repair of joints and tendons. In fact, because NSAIDs slow your body's natural production of glucosamine and chondroitin, it's probably a good idea to take these as dietary supplements if you are currently taking a lot of pain relievers.


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Treatments

2 GENERAL GOALS:

A. REPAIR
B. ANALGESIA (Pain Relief / Inflammation Reduction)

We will look at both in turn...

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THE REPAIR AGENTS


1. Glucosamine/Chondroiton:

Rationale for Use: Likely the most popular, both are natural building blocks used to repair connective tissue such as cartilage, tendons and ligaments. Because your body is slow to make glucosamine, taking it as a supplement speeds joint and tendon healing.

Chondroitin is an advanced molecule, created when many glucosamine molecules stick together. It is closer to being cartilage than glucosamine is, but isn't as well-absorbed (only 10 percent to 15 percent is absorbed, compared to 90 percent to 98 percent for glucosamine). Chondroitin is also a bit more expensive at about $1 per gram, whereas glucosamine goes for about one-third less. As a result, chondroitin is sometimes not marketed as aggressively, but evidence suggests it's as good or better at supporting connective-tissue renewal as glucosamine.

I am NOT, however, fond of supplemental response supplied by the oral ingestion of the aformentined said agents (this is glucosamine included), I DO think that research supports the use of such items in topical preparations with improved efficacy, if true efficacy can be claimed in the first place.

Both supplements have been used successfully to reduce osteoarthritis symptoms and to speed healing of joints. However, chondroitin has the unique ability to distract enzymes bent on destroying cartilage, causing them to target chondroitin instead. The chondroitin that gets chewed up is then converted to ordinary glucosamine and used to heal joints and tendons.


2. Vitamin C / Hydroxyproline / Hydroxylysine:

Rationale for Use: Each of the aforementioned 3 agents are actually quite imperative in any kind of tissue (namely as collagen is concerned) growth/repair. The amounts of vitamin C required for human health are far from established; the picture gets even trickier when considering wound/tissue growth/repair. Linus Pauling's suggestion that human needs for this vitamin probably have been underestimated by a factor of 10 or more has frequently been ignored or refuted by rhetoric rather than by sound experimentation. The thinking was still enough to gain Pauling the Nobel Prize and I am convinced as a water-soluble concern for true overdose is limited, so my own orthomolecular dosing parameters will be established for this trial.

There is also some suggestion that the use of the said agents can aid in analgesia. The presentation of cartilage auto-antigen (types II, IX, and XI collagen, aggrecan, and link protein), in conjunctionwith a major histocompatibility class II receptor by theantigen-presenting cell, is believed to initiate the inflammatory cascade. Offering up the repair agents sometimes thwarts this in adequate cross-linking of the collagen strands in repair. I am still using this as a repair agent. Hopes that it may offer analgesic response would simply be added benefit.

These particular agents will all be taken through oral route as I like the essential oral bioavailability in contrast to the aformentioned gluc/chond agents.


3. Hyaluronic Acid:

Rationale for Use: Hyaluronans are large polysaccharide molecules found naturally in the synovial fluid, which help to create a viscous environment cushioning joints and preserving normal function. Hyaluronans are used extensively in the management ofosteoarthritis of the knee and clinical trial results have documented their effectiveness for this indication. One of the nice things is that the growing body of evidence also supports use of the hyaluronic acid stucture in treatment of chronic pain versus the acute inflammatory variety.

Usually the growing body of research centers on the use of said agents through injection, a route I am trying to essentially avoid. That said, oral bioavailability has been shown as less than stellar. Again, this leaves us with few options to increase the efficacy of the said agent - that of which I am going to try also centers on transdermal.

[dinoiii]

THE ANALGESIC AGENTS


1. Methylsufonylmethane (MSM):

Rationale for Use: I think this agent has great potential as a organic sulfur donor which is the kind that the body can absorb and use and this in turn can reduce inflammation. The best thing about it, all acute, intemediate, and long-term studies indicate that MSM exhibits very low (virtually nil) toxicity NO MATTER HOW IT IS ADMINISTERED. How low? Some authors describe it as similar to that of water (but even water can be abused).

One of the most significant applications of MSM is that of pain reliever, due to a demonstrated ability to alleviate pain associated with systemic inflammatory disorders. People with arthritis report substantial and long-lasting relief while taking daily doses ranging from 100-5000 mg.

The beneficial effect here is due in part to the ability of MSM to sustain cell flow-through, allowing harmful subbstances such as lactic acid to flow out while permitting nutrients to flow in, thereby preventing the pressure buildup in the cells that causes joint inflammation in joints and elsewhere. [please note: Some of the substances in Clout and Body Octane, which I will also be using along side this trial also accomplish this in part!]

The nerves that sense pain are located primarily in the soft tissues of the body, such as the muscles. Many types of pain can be attributed to a pressure differential involving the cells that make up these tissues. When the outside pressure drops, the cells become swollen and inflammed. The nerves register the inflammation, and pain is experienced. Often, contributing to the pain are rigid fibrous tissue cells, which lack flexibility and permeability - kind of like that in the supraspinatus tendon. MSM has been shown restore flexibility to the protein layer of the cell walls, allowing fluids to pass through more easily. This softens the tissue and helps equalize pressure, treats the cause of inflammation, UNLIKE ASPIRIN, which treats the symptom by shutting off the nerve.


2. FISH OIL:

Rationale for Use: A standout among joint supplements is fish-oil extract, more specifically, the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid. Both EPA and DHA fight joint-damaging enzymes called collagenases and reduce inflammation, factors believed to play a role in joint aches and pains, including arthritis. As a result, fish oil is a great supplement for the active guy who wishes to reduce joint and tendon pain and prevent any damage.

In fact, a number of top-notch clinical trials, including one published in Journal of Rheumatology, have found that about six grams of fish-oil extract per day reduces symptoms of rheumatoid arthritis (which is essentially joint inflammation raging out of control). To get the equivalent amount of omega-3s from your diet, eat fish twice a week (see table for best choices). For instance, two nine-ounce salmon steaks a week provide about 42 grams of fish oil.

[Please Note: Part of my Omega-3 requirement will come in the form of BIG FISH from MAN Vaporize, of course, but I will get to the doses I will be using below.]


3. S-adenosylmethionine (SAMe)

Rationale for Use: For those familiar with my writing, you know I am A HUGE FAN of SAMe use for many ailments, and joint pain is one. Although many will likely critique that the dose needed to achieve joint releif based on very early clinical trials and the essential high cost of this support supplement will not warrant it's use in many people, I am going to use it DESPITE COST at a trial mimicking dose for true efficacy as this joint pain has gone on far too long as discussed above.


4. Celadrin (The registered proprietary blend of various cetylated, esterified fatty acids (cetyl myristoleate, cetyl myristate, cetyl palmitoleate, cetyl laurate, cetyl palmitate, cetyl oleate)

Rationale for Use: It is actually suggested to be superior to ALL of the aforementioned agents and has a couple of clinical trials to boot in the Journal of Rheumatology (although no head-to-heads so I am still employing the other agents). The great part is that both trials were double-blinds unfortunately one was an oral preparation and the other a topical. To further this, there were two trials in the Journal fo Strength and Conditioning also showing efficacy in replicated fashion to the topical, however, I will already be using a topical preparation for this trial so I am going to be trying it as an oral and based on structure alone - theory would likely dictate the oral bioavilablity to be sufficient as well as the first trial.

All of this suggested, I am going to ingest a dose that mimics the clinical trial in the Journal of Rheumatology to offer up aid.



PLEASE NOTE:
The thing with the Fish Oil and the oral Celadrin is that they MUST be adjusted into my caloric intake for the duration of the trial - which will likely sit at 68 days. Why 68 days? This mimics the upper-limit of some study protocols as listed within the information above...While some study info is based on shorter time protocols, I am emeshing the longest trial with the basis of an adequate exercise protocol/treatment plan.



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DEJA REVIEW

I have reviewed everything as best I can. Some may say - why aren't you using cissus Dana? Well, as I have said in other pieces, I feel cissus harbors a low toxicity and if I were recovering from a fracture...I might actually include it. There has been hypothesized suggestion of an estorgenic component that leaves me a little unsure about some of the current ketosteroid preps available.

All of that said, I would like to review what my entire supplemental protocol will be for the duration of this trial (one that is unmatched IMO) on the review end:

(1) VPX Glucosacream: I have had success with this product in the past and absolutely swear by it! I have turned many of my clients on to it as well for years. It is a topical preparation of Glucosamine HCl, MSM, Chondrotion Sulfate, Hyaluronic Acid as the listed actives. There are some inactive cetylated molecules including fatty acids that may contribute to efficacy. MY DOSE: 2 generous applications of the cream, morning and night.

(2) Fish Oil: I will employ the aid of 2 red gels of MAN Vaporize x 3 doses evenly spaced throughout the day. Because this will supply me at about 1/2 the fish oil I want, I will add in 3 grams from an alternative source as I don't want additional Sesamin on top of this.

(3) SAMe: Because of my money going to a rather high dose here, I am going to support an independently-tested product (consumerlabs.com) and use Vitamin Shoppe SAMe which has passed with its 1,4 butanedisulfonate, disulfate [sic] tosylate formula @ 400mg x 3 doses per day.

(4) Celadrin: I am going to dose this at 3 caps, 2 times per day - yielding 2100mg of proprietary cetylated fatty acids.

(5) Vitamin C/Hydroxyproline/Hydroxylysine: I will use orthomolecular dosing parameters as described by Linus Pauling to dictate much here, but these will all be rather cheap consumerlabs.com tested generic variety. I have yet to purchase this last one to date...so I will have to make you aware of how this goes come tomorrow for full indication.




As an additional note for the log, the aforementioned supplements are THE MOST SUPPLEMENTS I HAVE USED at one time to date. I tend to use one-three ergogenics and then supports. Here, the use of the top 5 agents as adjuncts to my own training rehab is an all-time high however recall I am attempting to avoid resorting to any of the following: surgery, corticosteroid injections, PT, and/or pharmaceutical analgesics. The joint supps alone will likely set me back about an additional $100 per month going at the doses I have projected - fortunately, I already have the glucosacream from last year, SAMe is a virtual staple and I have some on board already, the Vaporize I had before I even started consulting for MAN, and Celadrin was an easy addition. Now, if I can merely shovel myself out from the snow that covers my driveway, I may get the Hydroxyproline/and Hydroxylysine to cover my regime adequately.




* PLEASE NOTE: I will also be using the additional supplements - CLOUT/BO as I am NOT stopping my workout routines ... simply modifying them, which you will see later. And I will likely include in head-to-head fashion BLUE PRINT after seeing how much of a potential immediate responseis seen with the others. It will be Blue Print (in pain control role) versus the others. Stay tuned...

D_

[dinoiii]

Movement

One of the key points to this is that I will NOT be abandoning a strength training protocol (however, volume will be significantly decreased in an Upper Body/Lower Body split as described below), however, I will opt to change the sometimes static position I find myself in in between sets. Constant movements will be employed and coupled with alternative shoulder rehab training every other day.

The shoulder Rehab training I have planned will look as follows:

Weeks 1-5
1. Passive range of motion (PROM) and active-assisted range of motion (AAROM) (wand, pulley) within pain tolerance

2. Sub-maximal isometrics for shoulder musculature

3. Manual resistance for scapula motions

4. Postural awareness education

5. Therapist supervised UBE for motion, avoiding substitution or impingement

6. Gentle soft tissue mobilization

7. Modalities as indicated for pain or inflammation


Weeks 5-10

1. Progress PROM and AROM as tolerated

2. Joint mobilization for scapula and glenohumeral (posterior capsular stretching)

3. Strengthening exercises for scapula stabilizers and rotator cuff

4. May include PRE’s theratube/band, PNF, UBE, and weight equipment

5. Emphasis of strengthening, with postural awareness

Goal: Involved shoulder AROM grossly within normal limits by 6 weeks without shoulder hiking


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Exercise Setup:

Monday: Upper Body (Chest, Bis, Tris)
- while this is an "upper-body" day it comes with 2 exceptions, I will NOT train back until general lower body days and direct shoulder resistance training will be fielded on Saturdays alone alongside abs and calves.

Tuesday: Lower Body + Back
- while this is a "lower-body" day it comes with one addition and one exception as I have alluded to above. I will NOT directly train calves (they will be done on Saturday), and I will ADD back to general lower body sets (quads/hams).

Wednesday: Off

Thursday: Upper Body #2 (Chest, Bis, Tris)
- repeat Monday's workout split, yet using different resistance moves in this session.

Friday: Lower Body + Back #2
-repeat Tuesday's workout split, yet using different resistance moves in this session.

Saturday: Ancillary Circuit Training
- For those familiar with my writing, this is old hat. For those that aren't, this includes, direct shoulder training, abdominal work, and calf work ALONE - nothing else will be trained on this day.

Sunday: OFF



More to follow about individual techniques and training being used in each part of the above...and how this has been modified from former training and how the progress of my shoulder is coming.

Stay tuned...

D_

[growstrong]

awesome article D!

[B-natural]

the second thread cuts off part of the info given, how can this be adjusted?

[dinoiii]

Originally Posted by B-natural

the second thread cuts off part of the info given, how can this be adjusted?

Unsure - perhaps admin can adjust it.

On my screen the whole second post appears though the pictures do expand the length of the columns. If any of the computer gurus have such information. I can cover supplements and such, but unfortunately - computers is FAR from my specialty. HA!


D_

[Sampson]

Originally Posted by dinoiii

Unsure - perhaps admin can adjust it.

On my screen the whole second post appears though the pictures do expand the length of the columns. If any of the computer gurus have such information. I can cover supplements and such, but unfortunately - computers is FAR from my specialty. HA!


D_

The second post appears fine on my screen as well. The pictures do expand the columns slightly, but not too much. What screen resolution / browser are you running?

I am going to get an image resize script up soon, so when people do upload images that are too big the script will automatically resize them to fix within the allocated space.