Dear Drs. Miles and Ray,
Thank you for taking my question. I am a 36 year old Male, and I have been training for several years. I am 6ft 2in and 225 lbs. About a month ago I performed a large number of dips. Over the next week or so, I noticed pain when moving a glass to my mouth with my right hand to drink. I rested and took NSAIDs for a week with no improvement. My primary care physician diagnosed me with biceps tendonitis on physical exam and recommended physical therapy.
My therapist examined me and said my right shoulder was rolled significantly forward, possibly due to poor posture (as a detective, I am in a car and at a desk quite a bit). She noticed the muscles in my delta and shoulder and back were quite a bit smaller than on my left. She also said the injury was likely a long time coming because of the poor movement patterns generated by my posture.
I am currently on a program of lying on a lacrosse ball between my shoulder blade and spine to get my rib cage to go forward since it wasn’t before. I am stretching a very tight pec major and minor and stretching the biceps tendon. Also, of course, I am concentrating on improving my posture. She said it was a good idea for me to do pendlay rows, double overhand deadlifts, back squats, bit no pressing movements. I should mention I rarely did rows or back work before this, which may have contributed to my injury.
Would you add anything to my rehab? I’m pretty depressed that I let myself get to this point. I would really appreciate taking some barbell medicine.
Mike
Mike,
I’m sorry to hear you pissed off your shoulder. I typically attempt to extend a professional courtesy to other therapists but your therapist sold you one some bullshit. Having a shoulder “rolled forward” is a subjective call and does not have any correlation with having any symptoms. Neither does posture, but it is an often told narrative. Any therapist that fear mongers by saying that an injury was a “long time coming” is doing a disservice to our profession. We have never met but I can say without a doubt that you are a resilient human, not so prone to injury that you need some Damoclean sword put over your head by a cut rate therapist.
From what you have presented so far it sounds like you likely just exceeded what you were adapted to during your dip routine. Honestly, it happens to the best of us at times and does not have anything to do with posture, rolled shoulders, lacrosse balls and such. You were just trying to do something you weren’t quite adapted to yet. It is likely that you are experiencing some biceps tendinopathy, but this is a common thing we see in lifters, and common typically means we know how to address it. What does your current programming look like and what did it look like leading up to your symptoms? By that I mean split, were you running a template, do you use RPE as a guide or percentages, the more information the better here.
I would toss that lacrosse ball or find a local high school team that can at least put it to good use. What we need to start working on for you is some load management. If you are symptomatic we can start finding ways with which to train around the injury while stressing your shoulder in such a way that we facilitate healing. The heuristic essentially has three steps:
- Work within an acceptable range (this does not need to be pain free, but certainly pain manageable)
- Tendons tend to tolerate tempo work well whether this be from a press or even an isolated preacher curl (yes readers, I just advocated for a curl in programming)
- Realize that tendon healing does typically take time and it is about developing capacity to training
You’re going to get through this man, don’t let another therapist tell you otherwise. Set backs suck, but this is typically where we learn the most about our training programs and how to perform them better. If everything went okay all of the time we would have no frame with which to know how well we are actually doing.
Give us a little more information regarding your training history and goals and we can help you work through this. Also, I’m going to attach a large piece written by Jason Eure on what you have going on. It should help to give you a better frame on getting through this issue. The good part is it is titled “training with biceps tendiopathy” not rolling on a lacrosse ball with biceps tendinopathy.
​​​​​​Derek
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Wow. Tha is so much for your timely and thoughtful response. First, my training history: I ran finished LP in May and took a couple months off while moving houses. My lifts were as follows:
Back Squat 435# for a 5RM
Bench Press: 265 for a 5RM
Press:170# for a 3RM
Deadlift: 430# for a double
I started back in August doing 5 3 1 for n ok googood reason and have been out touch with pressing of any kind since injury in mid November. I’m running LP right now for my dead and my back squat. My deadlift is 380# and I squatted 335# today for my fives. Like j said. I’m not pressing. I could pick up a bar and press 135# for a set of 8 if I wanted to, and with little discomfort; it’s the idea of angering up my biceps that prevents me. Same story for the bench, where I could be back at 225# in a couple weeks. I just use percentages right now. Looking forward to getting some work done.
Cheers,
Mike.
P.S. thanks for the article. -M
No problem. If you took a some time off from training for moving I would not be overly surprised if you just exceeded the capacity of your tendon (shoulder) for training. Might I suggest not shooting for 135# for 8 but rather incorporating a press day of 4x6 at RPE 6 to just get some confidence back with the movement. Typically, when we get in a rut and expect a movement to hurt, we are really good and making it hurt. This really is about working with the window of tolerance for the tissue as it adapts. I typical tendon loading protocol looks something like:
Week 1-2: 4 sets of 12 at RPE 8
Week 3-4: 4 sets of 10 at RPE 8
Weeks 5-6: 4 sets of 8 at RPE 8
Weeks 7+: 4 sets of 6 at RPE 8
For a biceps tendinopathy utilizing preacher curls can be the better way to go. The big points being this should be utilized with slow, controlled movement (3-0-3 tempo) and tendons are slow to heal. Almost always we can start making symptoms feel better quickly but there will be a ceiling at which symptoms are felt. The goal with training is to continuously raise this ceiling.
Derek
Should the pressing movements be performed at tempo? Just the curls? I’m noticing a tremor in right biceps close to and at lockout on the bench. Thanks!
It is not a bad idea to run the presses at tempo until symptoms subside.
Derek
I’ll run lifts at tempo until symptoms subside. Strict press feels ok, like I’m not really compressing the tendon in the joint, which makes sense since I don’t lower the bar all the way to my collarbone. I’ve widened my grip on the bench, but I’m symptomatic just sitting still. Do I understand correctly that if I am feeling the tendon compress in my shoulder during the bench, that I should be limiting my range of motion? Based on the article, it sounds like I should move to pin presses or floor presses. Also, I’m alternating press and bench in the standard Week 1: A B A Week 2: B A B template. Higher frequency? Thanks for everything.
Mike
Mike,
I would caution against getting hung up on “feeling the tendon compress.” It is easier to think of it in terms of “having symptoms.” Most of the time the more we get hooked on a singular cause/mechanism/symptoms the harder it is to work around/through it. You are correct in that if you are experiencing symptoms limiting the motion via a pin press can be ideal with a gradual reintroduction of range. Sometimes what happens is it starts feeling better and there is an urge to go straight to pressing full ROM again. I would advocate for incremental steps and a slightly slower process. If we are going to run a standard tendon protocol an ABABAB split is a perfectly fine frequency.
Derek