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Training discussion on Muscle, Joint, and Shoulder Injuries, within the Bodybuilding Forum; INFORMATION about TRIGGER POINTS and their TREATMENT Compiled by Dr Diana Cross What are trigger points [TPs]? A trigger point ...


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Old 04-15-2006, 10:20 AM   #11
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INFORMATION about TRIGGER POINTS and their TREATMENT
Compiled by Dr Diana Cross


What are trigger points [TPs]?
A trigger point is simply a small contraction knot in muscle. This knot feels like a pea buried deep in the muscle, and can feel as big as a thumb. It maintains a hard contraction on the muscle fibres connected to it, thus causing a tight band that can also be felt in the muscle. These trigger points in muscles and in the thin wrapping around each muscle [called fascia] are called myofascial trigger points, to distinguish them from trigger points which can occur in other soft tissues such as skin, ligaments and tendons, and also in scar tissue.

Are TPs the same as a muscle spasm or strain or tear?
No, a TP is not the same thing as a muscle spasm. A spasm involves a violent contraction of the whole muscle, whereas a TP is contraction in only a small part of a muscle. A strain or tear involves physical damage to the muscle or tendon fibres, Such damage has not been demonstrated in studies of TPs. [However, such injuries may predispose one to developing TPs there later on.]

Why are they called trigger points?
Pulling the trigger of a gun makes a noise in the gun but it also sends out a bullet that causes pain at a distant target site. Pressing firmly on muscle TPs hurts right where you are pressing, making you jump, wince and pull away. But, more importantly, TPs also send ['refer'] pain or tenderness to some other site, often quite far away. So, for example, a headache may not be caused by a problem in the head itself, but have been sent to the head from a TP on the side of the neck. Never assume the problem is at the place that hurts.

What does this referred pain feel like?
The referred pain caused by TPs is usually steady, dull and aching, often deep. It may occur at rest, or only on movement. It varies from being a low-grade discomfort to being severe and incapacitating.

Are TPs common?
Myofascial trigger points are among the most common, yet poorly recognised and inadequately managed, causes of musculoskeletal pain seen in medical practice. Unfortunately, many general practitioners and orthopaedic surgeons do not know about TPs, and as TPs do not show on XRays or scans, the patient may be told there is nothing wrong with them or that there is nothing that can be done to help fix their pain.

What common conditions are thought to be due to referred pain from TPs?
TPs are known to cause or contribute to headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome and tennis elbow, and many kinds of joint pain mistakenly ascribed to arthritis, tendonitis, bursitis, or ligament injury.

What other symptoms may TPs cause?
Apart from pain, TPs may cause numbness, tingling, weakness, or lack of normal range of movement. TPs can also cause earaches, dizziness, sinus congestion, nausea, heartburn, and false heart pain. And they may result in depression if pain has been chronic.

How can one know where the TPs are?
It is important to realize that the TPs themselves do not hurt, [other than when you are actually pressing firmly on them.] In other words, the gun has a silencer on it, so you don't know there is a gun or that it is being fired. You only know that you're wounded. Most patients are surprised when I locate a very painful tight spot in a muscle well away from where they tell me their pain is. They were usually completely unaware that this painful tight spot even existed, let alone that such a small spot could be the cause of all their pain.

So how did I know where to find that spot?
Fortunately, referred pain occurs in predictable patterns, which have been clearly mapped out in The Trigger Point Manual by Simons and Travell. Using their maps I know which areas to search for the TPs that characteristically send pain to the place where you are hurting. I then feel for a tight muscle in that area, feel for tight bands within that muscle, and localize an area within the band which is exquisitely tender and that is the TP. As I press or twang it, the muscle may twitch. As I keep pressure on it, it will cause your usual referred pain, thus confirming that we've got the spot.

Could there be more than one TP causing my problem?
Yes, TPs tend to gang together, so in practice it is common to find more than one TP in the tight muscle, and more than one muscle whose TPs refer pain to the area where you are hurting. All your TPs need to be hunted out and treated before you'll gain full relief of your symptoms. I will show you the relevant TPs for your problem, and after a while you'll become expert at finding them for yourself. .

What causes TPs to develop?
All of us develop tight bands in our muscles as we age, but some people have more than others, for various reasons that are listed in the red box labelled: 'Predisposing factors'. Then, some of these tight bands go on to develop TPs in them, when one or more 'Precipitating factors' arise. For example, a TP may develop following an acute muscular strain such as during a car accident, a fall, a sprain or fracture, or excessive or unusual exercise. Or following chronic overload of the muscles used to maintain posture because of poor sitting, working or sleeping habits, or by repetitive work tasks.

Could poor general health be making my TPs even worse?
Yes, particularly if your pain has been happening awhile, it is very likely that one or more of the following 'Perpetuating factors' is present: Mechanical stresses such as a short leg, flat foot, poor posture, or immobility. Nerve root pressure, eg sciatica. Chronic internal diseases, and some prescription medications. Nutritional deficiencies, especially vitamins C, B-complex and iron. Hormone imbalances [low thyroid hormone levels, premenstrual or menopausal] Infections [bacterial, viral or yeast] Allergies [wheat and dairy in particular] Poor oxygenation of tissues [aggravated by tension, stress, inactivity, poor sleep, smoking ] These factors MUST be detected and corrected if specific treatment of the TPs is to be successful or lasting, so your doctor will spend some time sorting these out with you. Chronic fatigue syndrome and fibromyalgia also predispose one to develop TPs, [in addition to all the other tender spots characteristic of those conditions].

So how long will the pain take to get better?
With TPs of recent onset, significant relief of symptoms often comes in just minutes, and most acute problems can be eliminated within 3 to 10 days. But longer-standing chronic conditions are more complex and less responsive to treatment. None the less, even some of these problems can be cleared [in as little as 6 weeks] IF you persist with treatment AND if you fix the Perpetuating factors referred to above.

How are TPs treated?
TPs can be treated in a number of different ways, depending on the speciality or training of the practitioner. Doctors may use local anaesthetic, saline, or cortisone injections, but acupuncture needling, use of a cold spray whilst stretching the muscle, or specific trigger point massage also works. Some physiotherapists or masseurs have a real knack in treating TPs, and I can guide you as to who they are. However there are good reasons to learn how to apply trigger point massage to yourself. With self-treatment you don't have to wait for an appointment, you can get help whenever you need it, and you don't pay a cent. You can be the expert in knowing how to get rid of your own pain.

How does massage work?
In 3 ways: Massage breaks into the self-sustaining vicious circle that has kept the muscle contracted. It increases the circulation, which has been restricted in the immediate area by the contracted fibres, thus enabling oxygen and nutrients to flow to the spot. It directly stretches the trigger point's knotted muscle fibres.

What's the best way to massage them?
The Trigger Point Therapy Workbook by Clair Davies gives the following guidelines: 1. Use a tool if possible [such as a firm rubber ball] and save your hands. 2. Use deep stroking massage, [a repeated milking action] not static pressure. 3. Massage with short repeated strokes, moving the skin with your fingers, and releasing at the end of each stroke to go back to the starting point. 4. Do the massage stroke in one direction only, whether with the grain of the fibres or across them. 5. Do the massage stroke slowly, no more than one stroke per second. 6. Aim at a pain level of 7 on a scale of 1 to 10. 7. Limit massage to one minute per trigger point. 8. Work a trigger point 6 to 12 times per day, until pressure on it elicits a pain level of only 2 or 3. 9. If you get no relief, you may be working the wrong spot. Is there anything more I need to do after massage has relieved the symptoms? Yes. After massage it is very important to: Apply a hot pack covered with a dampened flannel or towel to the treated area for a few minutes. Then gradually and gently stretch the treated muscle through its full range of movement 3 times, with a pause to deep breathe and consciously relax between each cycle.

What else can I do or avoid to achieve lasting recovery?
Learn respect for your muscles. They were not designed to be held for long periods in a sustained contraction or in a fixed position. Vary your tasks each day. Lift very carefully.
Slow your working pace, and take short rests frequently, especially if feeling muscle fatigue.
Do a daily program of passive stretches that puts the affected muscles through a full range of movement, and repeat the stretches throughout the day. Be like the cat-- it rarely tries to walk after a sleep without first stretching smoothly and slowly.
Massage any TPs up to a dozen times a day, for a minute at a time, as described above.
Learn relaxation techniques, [eg yoga, meditation].
Always watch your posture when sitting, reading, using the computer car or phone. Don't stay too long in any one position.
Work out what particular postures, movements and activities stir up your TPs. If you don't have to do that activity, then don't. If you do, then modify how its done.[eg use the other hand].
Avoid getting the muscles cold, by wearing an extra warm layer of clothing, and adjusting heating etc.
Correct any imbalances in your diet, and take vitamin and mineral supplements as recommended by your doctor.

What about exercise?
Exercise should be regarded as a prescription, and the kind of exercise prescribed depends largely on how active your TPs are at that time. Your physio will give you the details.
When the TPs are very active and you have pain at rest, then gentle stretches and hot packs are your limit
Once the TPs are inactivated and constant rest pain fades, then a carefully graded exercise program is needed to increase muscle endurance and strength. This involves muscle lengthening exercises [adding a new exercise on alternate days], before working up to shortening exercises. Post-exercise soreness and stiffness should not last longer than 3 days or the program needs altering.
Then a regular conditioning program is recommended, at least twice a week, for example swimming or cycling.

Would the TPs get better if I just rested up?
Yes and no. Studies have shown that with a short period of rest and the avoidance of whatever activated the trigger point, the pain symptoms may disappear over a few weeks. This makes people believe their problems have gone away. But, if you examine the muscle properly you will find it is still tight stiff and weak, and still tender when pressed on. In other words, the TPs are still there; they are just lying dormant [latent], and not causing referred pain at that time. The bad news is that they can be very easily reactivated to cause pain again, by acutely overloading the muscle in a new or repetitive task, working or sleeping in an awkward position, chilling the muscle, or during emotional stress, fatigue, or viral infections. How much it takes to reactivate a latent TP will depend on the degree of muscle conditioning, so keeping fit can help reduce the likelihood of this. But the only way to get rid of the TPs for lasting relief is through actively hunting out and treating all the active and latent TPs. Although this involves more effort, its truly worth it in order to escape "the endless replay" of TP pain.

REFERENCES:
Travell J., Simons D.: Myofascial Pain and Dysfunction, the trigger point manual, Vol 1 & 2.Williams and Wilkins 1982 Davies C.

The Trigger Point Therapy Workbook, your self-treatment guide for pain relief. New Harbinger publications 2001

Trigger Point Diagram Cascade for Diagnosis and Management
(Large page download 96k )
By Dr D Cross

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Old 04-15-2006, 01:43 PM   #12
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Default Shoulder Problems Overview

All About Shoulder Pain

By: Michael Kurilla

Shoulders receive the lion's share of work in the gym. Nearly all upper body routines involve the shoulder to some extent, if only to be held fixed and motionless for the specific movement. Even during leg work, the shoulders are involved with the stacking and unstacking of plates for all the leg routines. Shoulder pain can greatly hamper any training routine and tends to require long periods of time for complete recuperation.

Severe injuries can prematurely terminate the careers of professional athletes such as baseball pitchers with rotator cuff problems. For the non-professional athlete, even minor shoulder pain can lead to disturbed sleeping patterns from the inability to find a comfortable position at night. Part I of this two part series will examine shoulder anatomy in sufficient detail to highlight the basis for skeletal variations that can predispose certain individuals to persistent shoulder problems. Part II will go on to present routines for strengthening lesser known shoulder muscles and lifting variations to minimize further trauma.

Bear in mind that severe pain, extreme muscle weakness, or inability to perform certain movements may indicate a condition requiring medical attention. Advice presented here should not serve in place of a thorough medical evaluation since certain conditions may require specialized medical intervention or even surgery.

Due to its extremely wide range of mobility, the shoulder is one of the most complex joints in the human body. Because of its unusual bone structure and large number of muscle attachments, shoulder pain can be a daunting challenge to most physicians who typically recommend merely rest and anti-inflammatory medications for weeks to months as therapy which may or may not solve the problem.

In addition, chronic degenerative changes that accumulate from repeated trauma will likely increase the frequency of shoulder problems for most individuals as they age and continue lifting. While any single article can hardly be exhaustive on the subject of shoulder issues (whole books 16,17 have been devoted to the subject), this discussion will focus on one of the more common problems that results from a combination of unlucky anatomy, undesirable lifting technique, and insufficient attention to auxiliary musculature.

The Anatomy Of The Shoulder

The shoulder is the anatomical structure that links the arm with the torso. A wide array of muscles of particular interest to bodybuilders traverse the shoulder including: pecs, lats, delts, and even the biceps. Given that the lats and delts contribute to a wide upper body desirable by bodybuilders, much attention is focused on these muscle groups and considerable stress is applied to the shoulder. Pain and discomfort can dramatically compromise nearly any weightlifting routine.


The shoulder as a joint is classically described as a ball and socket (similar in design to the hip joint)1. The ball portion is derived from the end of the upper arm bone, the humerus, and resembles a ball stuck on the end of a long shaft, and is referred to as the humeral head. The socket side is formed from one corner of a roughly triangular flat bone called the shoulder blade (the scapula), that rests over the rib cage, high on the back and extends over the rib cage to the front of the body. The triangular form of the scapula has one side close to the midline of the back with the lower corner angling up towards the shoulder.

The third side of the triangle runs parallel to the shoulders across the top. The shoulder blade is thicker in its upper portion than the lower portion, so that the very top of the shoulder blade has a surface (rather than just as edge as with the other two sides of the triangle) with two edges (one towards the body and one away). The top edge pointing away from the body is called the spine and the surface of the top of the shoulder blade is slightly depressed and called the supraspinous fossa (fossa is the technical term for a depression). Moving along the spine towards the shoulder, a bony extension, called the acromion, juts out and arches over the top of the scapula just above the humeral head and can be felt as the bony top of the shoulder.

The acromion arches over the top of the scapula from back to front and connects to the collarbone (clavicle) to complete the shoulder girdle. Arising off the top edge opposite the spine, also at the shoulder, across from where the acromion begins and pointing forward over the chest, is a small bony knob called the coracoid process. The short head of the biceps muscles attaches to this piece of bone as well as a small muscle called coracobrachialis and the pectoralis minor muscle (underneath pectoralis major, the main 'pecs'). In addition, a tough ligament connects the coracoid process with the acromion.

The socket portion of the scapula that contacts the humerus is called the 'glenoid fossa,' but rather than looking like a true socket, the glenoid fossa is more open with the appearance of a saucer or rather like a golf tee with the humeral head as the golf ball. The reason for the openness is to permit a large range of motion in the joint. The downside to this large range of motion is the propensity of the shoulder to dislocate. A dislocation occurs when the humeral head moves beyond the confines of the glenoid fossa and slips over the lip of the saucer (your golf ball falls off the tee).

When any muscle acts across a joint, opposing muscles are contracted as well to stabilize the joint. Imbalances in strength between opposing muscles can potentially lead to injuries. With the shoulder, the anatomy is not as simple as a one dimensional joint (such as the elbow). Movement of the shoulder requires many different muscles to create the movement as well as other muscles to stabilize the shoulder joint. In addition, since the shoulder blade is only attached (by other bones) to the upper arm and collar bone at one end, the blade portion must be held fixed by additional muscles.

For example, serratus anterior (best seen in a well muscled, lean individual) is a small group of muscles that arises from the rib cage in front just below the pecs with the muscle bellies extending up and around to the back and disappearing underneath the lats. Serratus anterior attaches to the scapula along the edge closest to the middle of the back. Serratus's job is to prevent the shoulder blade from winging during shoulder movements; in other words, serratus pins the scapula to the back and so serves to stabilize the joint during movements.

The Rotator Cuff

As discussed above, the shoulder joint has an extremely wide range of motion. A key structure supporting the shoulder joint is the rotator cuff. The rotator cuff is concerned with two major functions, rotating the shoulder and cuffing the joint 5,34. Rotation may not appear as an obvious movement with regard to the shoulder.

To visualize shoulder rotation, place your arm at your side and bend the elbow to 90o, as if to shake hands, but maintain the upper arm against your side and keep you palm in (thumb up).

Keeping your upper arm against your side, bring your forearm and hand across your body to rest your palm on your stomach. That movement is internal shoulder rotation (the upper arm bone, the humerus, is rotating relative to the shoulder; internal is used to denote a movement towards the midline of the body). A more extreme form of internal rotation is to place the back of your hand on the small of your back, again with your elbow bent at 90o. Now keeping your elbow bent, lift your hand away from your body. One muscle of the rotator cuff, subscapularis arises from the underneath side of the shoulder blade (the side against the rib cage) and attaches to the humerus in such a way as to produce rotation of the humerus when contracted.

If the lifting of your hand away from your back produces extreme pain or is simply impossible to perform, injury to this muscle (or a tear in its tendon) may be the source. This problem requires medical attention. The opposite motion to internal rotation is external rotation (rotating your forearm away from your stomach with your upper arm against your side) and is produced by contracting two other muscles of the rotator cuff group, infraspinatus and teres minor. These muscles also arise from the shoulder blade, but on the outer side, and also attach to the humerus.

These three muscles are responsible for shoulder rotation, but the rotator cuff complex has four muscles and this is where the cuff component is involved. The fourth muscle is called supraspinatus and arises over the top of the shoulder blade (in the supraspinous fossa) and crosses the shoulder joint traveling underneath the acromion and attaching to the humerus just below the humeral head. Altogether, these four muscles (the three true rotators and supraspinatus) are the innermost set of muscles surrounding the shoulder joint and form a cuff around the joint.

Bearing in mind the shallow nature of the glenoid fossa and the propensity for the humeral head to dislocate, the contraction of all four muscles forms a tight wall around the lip of the socket to help hold the humeral head in position (centered in the glenoid fossa) 5. During almost any shoulder movement, these muscles are contracting to stabilize the joint throughout the movement by maintaining the humeral head centered in the glenoid fossa 34.

When you throw an object, the entire movement is designed to throw your arm away from your body. The object is thrown because you release your grip on it. Your arm and shoulder joint stay in place because the rotator cuff is holding the upper arm bone in place. This is why rotator cuff injuries are so devastating to baseball pitchers; a strong, intact rotator cuff is needed to allow for high velocity pitches without injuring the shoulder joint. Weakness or worse, injury to the rotator cuff can place undue stress on the shoulder joint during heavy lifting routines (because the humeral head does not stay centered in the glenoid fossa).

Strengthening the rotator cuff muscles, particularly the three involved with rotation is straightforward and basically involves movements as described above for internal and external rotation, but with light weights while lying on your side. The remaining muscle, the supraspinatus, is less straightforward and unfortunately, much advice over the years has served to compound problems 30, especially for those who are anatomically predisposed to have problems in the first place.

Impingement Syndrome

The supraspinatus muscle is involved with some of the most common causes of shoulder pain 15. To understand its involvement and how some individuals are predisposed to suffer more than others, an appreciation of the surrounding anatomy of supraspinatus is important. As discussed above, the supraspinatus muscle arises from the roof of the scapula (shoulder blade) and attaches to the upper arm bone (humerus) on the shaft just below the humeral head. Following along the muscle's path, supraspinatus travels between the shoulder joint itself (from below) and the acromial arch (from above).

This arrangement has supraspinatus traversing a nearly complete bony tunnel with a tough ligament closing the only non-bone portion (coracoacromial ligament - connecting the coracoid process with the acromion). In addition, being part of the innermost layer of muscle would have supraspinatus moving directly on bone which is not ideal. To cushion the muscle, supraspinatus sits (and slides over) on a 'bursa', a fluid filled sack that reduces friction between moving muscles and bones.

The attachment site on the humerus bone also deserves some attention. While the humerus is described as a shaft of bone with a ball-like end, bone shafts are rarely, evenly smooth across their surface. In particular, points of muscle attachments are typically raised and referred to as 'tuberosities.' Just below the humeral head are two such structures, the greater tuberosity, just below the acromion (on the side with your arm at your side), and the lesser tuberosity to the left in the forward direction (basically facing forward). The valley between the two tuberosities is a groove for the one of the heads of biceps' tendon to follow. Supraspinatus attaches to the upper edge of the greater tuberosity, just below the humeral head, adjacent to the biceps tendon.

The greater tuberosity has the potential to produce impingement in certain individuals who posses a specific hooked shape to their acromion 19,23,26,29,32,33,35. In some people, the hook is exaggerated (see www.aafp.org/afp/980215ap/fongemie.html for excellent visuals). As the arm is raised (as in a side lateral raise), the greater tuberosity and acromion come quite close (they 'impinge' on one another) with the bursa and the supraspinatus muscle sandwiched in between.

Compression alone can damage either the bursa (producing inflammation called bursitis 27, a common condition among older individuals) or the supraspinatus muscle itself (or its tendon) and is called impingement syndrome. The result is pain whenever, the arm is raised since supraspinatus when contracted, is pressing against the bursa to hold the humeral head centered in the joint. Also, with too much inflammation, while supraspinatus is cushioned from bone below with the bursa, the confined bony space (the bony tunnel it passes through) can cause the muscle to scrape the underside of the acromion from above the muscle which is also painful 10,25,28.

As discussed, the propensity for problems usually begins with an anatomical predisposition. Individuals with a more hooked acromion are at greater risk for impingement syndrome such as swimmers for example, due to repetitive overhand motions of the freestyle stroke 3,4,6,8,14. X-ray and other imaging studies have demonstrated that those individuals with the acromial shape most likely to cause impingement in fact, suffer the most from the syndrome 6,9,10,12,14,18,19,25,29,31,32.

Whether someone is born with an impingement prone condition or it develops over time is still a matter of debate; 13,23,24,33,35,36 but clearly, the presence of a hooked acromion is found more commonly in those individuals with impingement syndrome. The shape of the ligament connecting the acromion and the coracoid process can also influence the likelihood of impingement 20.

Past trauma to the shoulder can also lead to bone spurs that will also increase the likelihood of or aggravate impingement, by reducing the space in that bony tunnel for supraspinatus and the bursa to move through 11.Thus, there are many routes to creating the conditions for impingement syndromes. Once established, the chronic nature of inflammation and degenerative changes have a high probability of creating a state of ongoing trauma and further contributing to more inflammation and accelerating degenerative changes.

Thus, an individual who has suffered with shoulder discomfort in the past during upper body work is very likely to continue to suffer unless modifications in their routine are employed. There are several indications of potential a impingement syndrome 2,7,11,21,22. One clue to either bursitis in this region or injury to the supraspinatus muscle itself is tenderness just below the acromion. Another clue to supraspinatus problems is pain during movements that increase the chance of impingement. Pain or discomfort during a movement while your shoulder is in an internally rotated position is also a tipoff. Simply put, routines with palms down will position the greater tuberosity in the best position for impingement. Overhand wide grip lat pulldowns can do this.

Also, performing a lateral side raise and pointing your thumb down near the top of the lift is most likely to produce impingement because the shoulder is internally rotated and positions the greater tuberosity optimally for impingement. Finally, shoulder pain at night during sleep can also be a subtle clue to minor irritation from impingement. If someone is anatomically predisposed to these problems, pain and discomfort is likely when traditional lifting routines are employed. This is not a problem that can be 'worked through' in the classical sense; modifications to technique are required.

Part II will focus on exercises to strengthen the supraspinatus muscle. These exercises differ in form and style from common lifting routines. In addition, modifications from simple to extensive in standard lifting routines to employ for overall upper body work to reduce the likelihood of further aggravating suprapinatus will be suggested.

Reference List

1. 1972. Cunningham's Textbook of Anatomy. Oxford University Press, London.
2. Almekinders, L. C. 2001. Impingement syndrome. Clin. Sports Med. 20:491-504.
3. Arroyo, J. S., S. J. Hershon, and L. U. Bigliani. 1997. Special considerations in the athletic throwing shoulder. Orthop. Clin. North Am. 28:69-78.
4. Banas, M. P., R. J. Miller, and S. Totterman. 1995. Relationship between the lateral acromion angle and rotator cuff disease. J. Shoulder. Elbow. Surg. 4:454-461.
5. Bigliani, L. U., R. Kelkar, E. L. Flatow, R. G. Pollock, and V. C. Mow. 1996. Glenohumeral stability. Biomechanical properties of passive and active stabilizers. Clin. Orthop.13-30.
6. Bigliani, L. U., J. B. Ticker, E. L. Flatow, L. J. Soslowsky, and V. C. Mow. 1991. The relationship of acromial architecture to rotator cuff disease. Clin. Sports Med. 10:823-838.
7. Brossmann, J., K. W. Preidler, R. A. Pedowitz, L. M. White, D. Trudell, and D. Resnick. 1996. Shoulder impingement syndrome: influence of shoulder position on rotator cuff impingement--an anatomic study. AJR Am. J. Roentgenol. 167:1511-1515.
8. Cohen, R. B. and G. R. Williams, Jr. 1998. Impingement syndrome and rotator cuff disease as repetitive motion disorders. Clin. Orthop.95-101.
9. Epstein, R. E., M. E. Schweitzer, B. G. Frieman, J. M. Fenlin, Jr., and D. G. Mitchell. 1993. Hooked acromion: prevalence on MR images of painful shoulders. Radiology 187:479-481.
10. Farley, T. E., C. H. Neumann, L. S. Steinbach, and S. A. Petersen. 1994. The coracoacromial arch: MR evaluation and correlation with rotator cuff pathology. Skeletal Radiol. 23:641-645.
11. Fongemie, A. E., D. D. Buss, and S. J. Rolnick. 1998. Management of shoulder impingement syndrome and rotator cuff tears. Am. Fam. Physician 57:667-2.
12. Gagey, N., E. Ravaud, and J. P. Lassau. 1993. Anatomy of the acromial arch: correlation of anatomy and magnetic resonance imaging. Surg. Radiol. Anat. 15:63-70.
13. Gill, T. J., E. McIrvin, M. S. Kocher, K. Homa, S. D. Mair, and R. J. Hawkins. 2002. The relative importance of acromial morphology and age with respect to rotator cuff pathology. J. Shoulder. Elbow. Surg. 11:327-330.
14. Gohlke, F., T. Barthel, and A. Gandorfer. 1993. The influence of variations of the coracoacromial arch on the development of rotator cuff tears. Arch. Orthop. Trauma Surg. 113:28-32.
15. Green, A. 1995. Arthroscopic treatment of impingement syndrome. Orthop. Clin. North Am. 26:631-641.
16. Horrigan, J. and J. Robinson. 1991. The 7-Minute Rotator Cuff Solution. Health for Life, Los Angeles, CA.
17. Humphreys, C. L. 1999. Shoulder Injuries & Weight Training. MuscleMag International, Mississauga, ON CA.
18. Hyvonen, P., M. Paivansalo, H. Lehtiniemi, J. Leppilahti, and P. Jalovaara. 2001. Supraspinatus outlet view in the diagnosis of stages II and III impingement syndrome. Acta Radiol. 42:441-446.
19. Kitay, G. S., J. P. Iannotti, G. R. Williams, T. Haygood, B. J. Kneeland, and J. Berlin. 1995. Roentgenographic assessment of acromial morphologic condition in rotator cuff impingement syndrome. J. Shoulder. Elbow. Surg. 4:441-448.
20. Kopuz, C., S. Baris, M. Yildirim, and B. Gulman. 2002. Anatomic variations of the coracoacromial ligament in neonatal cadavers: a neonatal cadaver study. J. Pediatr. Orthop. B 11:350-354.
21. Neer, C. S. 1972. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J. Bone Joint Surg. Am. 54:41-50.
22. Neer, C. S. 1983. Impingement lesions. Clin. Orthop.70-77.
23. Nicholson, G. P., D. A. Goodman, E. L. Flatow, and L. U. Bigliani. 1996. The acromion: morphologic condition and age-related changes. A study of 420 scapulas. J. Shoulder. Elbow. Surg. 5:1-11.
24. Pfahler, M., S. Haraida, C. Schulz, H. Anetzberger, H. J. Refior, G. S. Bauer, and L. U. Bigliani. 2003. Age-related changes of the glenoid labrum in normal shoulders. J. Shoulder. Elbow. Surg. 12:40-52.
25. Prato, N., D. Peloso, A. Franconeri, G. Tegaldo, G. B. Ravera, E. Silvestri, and L. E. Derchi. 1998. The anterior tilt of the acromion: radiographic evaluation and correlation with shoulder diseases. Eur. Radiol. 8:1639-1646.
26. Prescher, A. 2000. Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle. Eur. J. Radiol. 35:88-102.
27. Santavirta, S., Y. T. Konttinen, I. Antti-Poika, and D. Nordstrom. 1992. Inflammation of the subacromial bursa in chronic shoulder pain. Arch. Orthop. Trauma Surg. 111:336-340.
28. Suenaga, N., A. Minami, K. Fukuda, and K. Kaneda. 2002. The correlation between bursoscopic and histologic findings of the acromion undersurface in patients with subacromial impingement syndrome. Arthroscopy 18:16-20.
29. Toivonen, D. A., M. J. Tuite, and J. F. Orwin. 1995. Acromial structure and tears of the rotator cuff. J. Shoulder. Elbow. Surg. 4:376-383.
30. Townsend, H., F. W. Jobe, M. Pink, and J. Perry. 1991. Electromyographic analysis of the glenohumeral muscles during a baseball rehabilitation program. Am. J. Sports Med. 19:264-272.
31. Umans, H. R., H. Pavlov, M. Berkowitz, and R. F. Warren. 2001. Correlation of radiographic and arthroscopic findings with rotator cuff tears and degenerative joint disease. J. Shoulder. Elbow. Surg. 10:428-433.
32. Wang, J. C., G. Horner, E. D. Brown, and M. S. Shapiro. 2000. The relationship between acromial morphology and conservative treatment of patients with impingement syndrome. Orthopedics 23:557-559.
33. Wang, J. C. and M. S. Shapiro. 1997. Changes in acromial morphology with age. J. Shoulder. Elbow. Surg. 6:55-59.
34. Wilk, K. E., C. A. Arrigo, and J. R. Andrews. 1997. Current concepts: the stabilizing structures of the glenohumeral joint. J. Orthop. Sports Phys. Ther. 25:364-379.
35. Worland, R. L., D. Lee, C. G. Orozco, F. SozaRex, and J. Keenan. 2003. Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J. South. Orthop. Assoc. 12:23-26.
36. Yazici, M., C. Kopuz, and B. Gulman. 1995. Morphologic variants of acromion in neonatal cadavers. J. Pediatr. Orthop. 15:644-647.

See also Shoulder Pain Management
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Old 04-15-2006, 04:15 PM   #13
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Impressive! Sorry it took so long to stick this beeatch!..
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Old 04-16-2006, 09:21 AM   #14
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Thanks bro mine.
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Old 04-16-2006, 09:33 AM   #15
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hey eric... i've been seeing this thread popping up every time i come online and sorry i havent visited it as yet.... my bad..

and although i havent read it a 100% (you'll have to forgive me for that), from how it look, i have to say AMAZING...!!!!!!

great work... i'll definitely read this sometime soon (possibly tomorrow)

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Old 04-16-2006, 10:15 AM   #16
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That's ok, Anuj. And thanks. This is not something I expect anyone to read until they actually need it, it's just a resource (I hope) to have handy.
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Old 04-16-2006, 10:20 AM   #17
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thats what i thought... and thats why i never read it 100%...
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Old 05-06-2006, 07:07 PM   #18
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Shoulder Fix It - 101 By Dr. David Ryan

Another Useful Article

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Old 05-07-2006, 04:07 AM   #19
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Article authored by Lynx100 found here.

The principles of rotator cuff injury management come down to these things:

1) Activity modification - People with acute pain can stay active but should avoid extremely painful movements. Activity can be increased as pain settles.

2) Analgesia - Simple pain killers or Non-steroidal anti-inflammatory drugs (NSAIDs) provide short-term pain relief.

3) Rehabilitation - There is some evidence that supervised exercise is beneficial.

4) Referral - Refer people to an orthopaedic specialist at six months if there is a poor response to treatment. However, if there is a massive tear it is best to refer immediately for orthopaedic evaluation. Delay compromises optimal outcomes for patients.

For an acute injury (one thats happened recently):

- Basic first aid measures RICE (rest, ice, compression and elevation)
- Apply ice to decrease swelling. Wrap the ice in a cloth to avoid freezing the skin. Apply the wrapped ice 10-15 minutes at a time. This is most helpful in the first 1-2 days.
- Support the arm in a sling to rest the rotator cuff muscles. The sling may be taken off at night. Anti-inflammatory medications may help reduce pain and swelling.
- Make an appointment with your doctor for assessment. The physician may ask you to be seen for follow-up, either by a primary care doctor or an orthopedic surgeon (specialist).
- Further imaging may be required to determine the degree and involvement of muscle tear. This is often done via magnetic resonance imaging (MRI).
- Early surgery (within 3 weeks) to repair the tendon is often needed, especially for younger, more active people with larger tears.
- Indications for surgical treatment:
o Usually for people younger than 50 years with complete or significant tears
o An option after failure to improve after 6 weeks of proper rehab
o If the person has a job that requires constant shoulder use

The major objectives of rehabilitation from a rotator cuff injury are to increase flexibility, obtain pain-free range of motion, and strengthen the muscles of the shoulders, upper back, front chest, and upper arms. In severe cases, you should avoid activity that causes shoulder pain altogether. In these cases, you can still maintain cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.

Stretching and stregthening of the 4 shoulder rotator cuff muscles (subscapularis, infraspinatus, supraspinatus and teres minor - for diagram, see link ive given to Marc's post. There he gives a good website outlying the basic anatomy of the shoulder musculature), as already mentioned the foundation of rehabilitation of rotator cuff injuries. Initially, soon after injury, after the pain has died down a little, it is best to start performing shoulder exercises to maintain the range of motion inthe shoulder and prevent scarring from the inflammation. This is best performed initially by isolating each muscle group and selectively training that muscle (known as Isometrics) - with no weights.

Phase 1 - Isometric exercises

The subscapularis is the anterior stabilizer of the rotator cuff and responsible for internally rotating the shoulder. It is best strengthened by holding your arm in front of the body, with the arm flexed to 90 degrees, and rotating the hand to touch the belt. The exercise can be performed while lying on your back with the elbow close to your side and flexed ninety degrees. Lift the weight until it is pointing toward the ceiling and then lower it slowly. Add small amounts of weight as you progress, making sure you are in minimal pain at all times. If it gets too painful, stop and rest.

The supraspinatus is strengthened by holding out your arm straight in front of the body, with the thumbs pointed toward the floor. Slowly elevate the weight to above the head. Stop if pain is produced in any portion of this motion, as the rotator cuff is under maximal stress in this position. As you feel better, you can slowly introduce small amounts of weight to continue strengthening of the muscles.

The infraspinatus is strengthened by holding you arm (and later on, a weight) in the position of the ski pole just prior to planting the pole. By rotating the arm from the neutral straight ahead position, to the externally rotated (out to the side) position, the infraspinatus and teres minor are strengthened. Again, this exercise can also be performed while lying on your side with the elbow close to your hip, and flexed ninety degrees. Rotate the weight until it is pointing toward the ceiling. Shoulder exercises are best performed with relatively light weights and multiple repetitions.

The logic behind stretching and strengthening the inflamed rotator cuff in order to speed healing and functional performance is as follows: the inflamed tissue is characterized by increased fluid between the cells, increased numbers of new blood vessels and inflammatory type cells. As a result of this inflammatory reaction, new collagen tissue is laid down in an effort by the body to heal the injured tissue. If the shoulder is immobilized during this time, the new collagen is laid down in a disorganized fashion, creating scar. The goal of gentle stretching, strengthening and anti-inflammatory medication, is to stimulate the cells to lay down collagen along the lines of stress, forming normal strong tendons. The combination of a good warm up, gentle stretching, strengthening below the limits of pain, icing after working out and anti-inflammatory medication has been consistently shown to speed recovery time in the strongest possible fashion.

After you are comfortable with these stretches and have minimal pain and good/fair range of motion in your shoulder, you can move onto resistance exercises. These usual start with what is known as tubing exercises. The 'tubing' is also known as a theraband, which is just a big rubber elastic band that you tie, at one end, to something and you hold the other end and pull the band thereby stretching it and providing resistance for your shoulder.

Phase 2 - Tubing exercises

External rotation: Stand resting the hand of your injured side against your stomach. With that hand grasp tubing that is connected to a doorknob or other object at waist level. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Repeat 10 times. Build up to 3 sets of 10.

Internal rotation: Using tubing connected to a door knob or other object at waist level, keep your elbow in at your side and rotate your arm inward across your body. Make sure you keep your forearm parallel to the floor. Do 3 sets of 10.

As you feel more confident and you find your strength increasing, you can add more resistance - either in terms of shortening the length of the theraband so you need more resistance to stretch it or by increasing hand held weights in small increments.

Of course, these arent the only exercises for shoulder rehabilitation. There are many more. Ive listed a few more below that ive found from a good website:


Overhead stretch
Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.

Cross-body reach
Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the front and across your body. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder.

Towel stretch
Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull the towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.

Shrugs
Stand with hands at sides with no weight in either hand. Raise shoulders to the point of pain and hold for five seconds. Relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, hold dumbbells of equal weight in each hand while performing this exercise. Add weight by using hand-held dumbbells as pain permits.

Bicep curls
Stand with arms fully extended at sides while grasping 2- to 5-pound weights in each hand, held palm forward. Flex the arms at the elbow to approximately 100 degrees, or to the point of pain, whichever comes first. Hold this position for 5 to 10 seconds. Return to the start position. Rest for 5 seconds. Repeat this exercise 10 times. You can increase the weight as pain allows and strength develops.

Triceps curls
Stand with elbows directed upward over the shoulders and with arms relaxed. Extend arms at the elbow so that the hands proceed upward to the point of pain. Hold this position for five seconds. Return to the starting position and relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, add weight by using hand-held dumbbells.

Chest raises
Lie on belly with hands extended along sides of the body. Raise the upper chest from the floor to the point of pain and hold this position for 5 seconds. Return to the start position and relax for 10 seconds. Repeat this sequence 10 times, 3 times daily.

Saws
Reach out and place the unaffected side hand on a corner of a table. Bend at the waist. Flex the injured side arm at the elbow and pull the injured side arm backward and upward as if sawing wood. Slowly bring the shoulder blades as close together as pain will permit. Slowly bring the injured side arm down to its beginning position. Repeat this sequence 10 times, at least three times daily.

Pendulum swings
Stand with the hand of the unaffected arm resting on the corner of a table and supporting some of the body weight. Slightly bend the knee on the unaffected side and extend the other leg sideways. Allow the injured arm to hang loosely over the unaffected side foot. By shifting the body weight, cause the relaxed injured arm to swing in circles to the fullest extent possible as limited by pain. Perform 25 swings in a clockwise direction. Allow the injured arm to cease swinging. Perform 25 swings of the injured arm in a counterclockwise direction. Repeat this sequence at least three times daily.

Flexed elbow pull
Bend and raise the injured side elbow to shoulder height. Grasp the injured side elbow with the uninjured side hand. Gently pull the injured side elbow toward the opposite shoulder until limited by first significant pain. Hold this position for 10 seconds. Relax for 10 seconds. Repeat this sequence 10 times at least three times daily.

Im sure there are other exercises that i havent mentioned.

Now people often say, when can i start weight training again? or when can i return to sport? There is no definite answer for that. It depend on the degree of your injury, how dedicated you are to your rehab and the rate at which your body heals. some people with minor tears can return to full contact sports in as short as 4 weeks. Other with larger tears have to have surgery and can be out for a year.

My advise to you is, dont rush it. Let your body take its time to heal. Be religious in doing your exercises and the results will come with time. Impatience is one of the biggest causes of re-injury.

And most importantly, always consult your physician for advice. While we can help you on these forums and point you in a right direction, nothing can replace a one-on-one physical examination and a good chat with your physician. This is essential.

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Old 05-07-2006, 04:14 AM   #20
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If you are having shoulder pain, go to this website: Click Here

Attached is a description of rotator cuff exercises I found at the same website [discuss bodybuilding].
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