Gents,
I was wondering if anyone there had any good resources for me as a barbell lifter to rehab mild to moderate but chronic tendinopathy in my left supraspinatus and infraspinatus. I’m a 49-year old lifter who’s been dealing with this condition for around three years after I discovered Starting Strength and ran an LP on myself. I believe I went into it with a relatively weak cuff on my left side due to a decades old un-rehabbed injury and got too caught up in what I perceive is a high intensity (>9 RPE) grind-it-out culture of SS. As a result I have developed the chronic condition that I have not been able to effectively train around. I joined SSOC just under a year ago and was assigned Darin Deaton as my coach given my history of tendinopathy. I trained with him for 4 months and was generally happy with my squat and DL progress. However I was disappointed that I didn’t get an effective enough knowledge of how to train around my condition during my time with him and that he didn’t seem to take the fact seriously that I wasn’t getting better over the 4 months time. I believe it was because his focus was to get me strong based on the SSOC contract and ensure I got my money’s worth rather than focus on healing me. He made this fairly clear at the start that he could only interact with me as a strength coach rather than a PT.
I’ve had two surgeries on this shoulder in the past three years including an open left biceps tenodesis, acromial decompressions, and synovectomies to deal with what were likely side conditions of my joint disease. Finally based on entirely my own slow efforts, I have been gradually getting better since December by eliminating the bench press and dramatically decreasing the intensity of my overheads, which I’m using to attempt to rehabilitate the tendons. I’ve experienced my most optimistic period the last week or so when I finally realized the combined same day workouts of squat/press/DL was just too damn much for my healing tendons, especially when the squats and DL were high intensity. I now press on different days than I squat/DL. I’ve also come to understand that while DLs are useful in applying good isometric stress to the cuff tendons, I need to keep the intensity low to modest for now to avoid irritating the tendon. However I really wish I wasn’t doing this all by myself. I have virtually no confidence in my orthopedic surgeon or standard PT to help me get back to productive lifting. Their general model is to help middle-aged men be pain free, not getting an avid weight lifter back to high intensity work.
Basically I was hoping I could get some advice or even better to work with someone who can really help me given my goals. I really need to have a program and protocol I can trust to get me from where I am now to someone who can execute say the Bridge 2.0 across my whole body. I’d like to be able to press and even hopefully bench press again at RPEs approaching 8 on a regular basis, however coach Deaton warned me that given the hypertrophic footprint of the cuff tendons after chronic tendinopathy, benching heavy with a barbell may not be in the cards for me and that only time will tell.
What I really need is a model of understanding how I can train around the injury and to understand what symptoms are normal as I’m healing and what symptoms are pathologically taking me in the wrong direction. For example, how much pain and discomfort is expected while my chronic tendinopathy heals, and how much is telling me I’m overdoing it and need rest. I think this is where the orthopedic and PT community (including coach D) have failed me. Does anyone have thoughts, suggestions, and resources that can help me so that I’m not on my own failing to recover for months and years on end? I’ve finally come to learn from your excellent podcasts that tendinopathy heals very slowly and that I’ve almost certainly been dealing with improperly set expectations on recovery time and process. But I’m tired of suffering.
Best regards,
Jeff
Sorry to hear about the shoulder issue.
When was your last shoulder surgery?
What narratives have you previously been supplied to validate treatment?
If you are dealing with a tendinopathy, this is a load management issue. Given your age, there really isn’t “healing” that needs to occur from the tissue sense. Allow me to explain. Tendinopathies have 3 stages in which they tend to present: 1) Reactive, think youth athlete who acutely over reaches in activity and has symptoms (pain and dysfunction), 2) Degenerative –portion of tendon presents with abnormal collagen formation and several other signs; this can readily occur in asymptomatic populations (no pain or dysfunction) and typically does occur without symptoms (welcome to aging card) 3) Reactive on Degenerative – this is what happens when someone over reaches and develops symptoms, similar to the youth athlete and can be chronic in nature. The difference here is the tendon has degenerative portions and we can’t really reverse that BUT we don’t have to based on current research regarding the topic. We can teach the tendon how to tolerate loading again while mitigating symptoms and returning to activity. Jill Cook, a leading researcher on the topic has coined this approach “Treat the doughnut not the hole”. Meaning, don’t worry ourselves with the degenerated portion but focus on managing load and symptoms while progressing toward patient goals. Much of the research regarding tendinopathies specifies we need to be loading the tendon and specifically via HSR (Heavy Slow Resistance). Think of this as tempo training through eccentric and concentric phases of the provocative lift. Regarding symptoms throughout the process, this IS a part of the process. Symptoms will spike while working through this load management issue but they shouldn’t leave you feeling debilitated afterwards or last for 24 hours beyond baseline.
For an in-depth discussion on the topic, check out a podcast Derek and I did for Clinicalathlete on the topic: http://www.clinicalathlete.com/clini…for-the-donuts
We’d also be happy to consult with you on this and develop a program for you to follow if you are interested. See here: Contact Us | Barbell Medicine
The good news, there’s nothing about this scenario that says you can’t meet your goals (specifically bench pressing) but it’s a matter of embracing the process and managing load accordingly.
Hi Michael,
I really appreciate your reply. I will give you a brief history including what I have been doing to date. I find your response very optimistic and quite frankly have run across some of these ideas in my own personal research to which I was directed from an earlier reply on this very forum. Specifically I looked into a PhysioEdge podcast by an Australian PT group that featured a guy by the name of Adam Meakins where they discussed Jill Cook’s research and the HSR approach. I’ve been trying some of things on myself and have made some progress, however doing it by myself is very difficult since I never really have confidence in how to properly program improvement and interpret my experiences.
I’ve had two surgeries on my left shoulder. I hope I am not being too detailed, but it’s sometimes hard to know what is relevant and what isn’t.
- Summer of 2015 was my first surgery where the surgeon used an MRI and arthrogram to diagnose loose bodies, degeneration of the tendon of the long head of the biceps, and inflammation of the infraspinatus/supraspinatus. They performed an open biceps tenodesis, removal of loose bodies, subacromial decompression, full synovectomy, partial bursectomy, and a distal clavicle resection. Recovery was long, painful and difficult mostly due to the biceps tenodesis. The doctor also noted some focal regions of high grade cartilage wear on the humeral head most likely due to calcified loose bodies stuck in the GH joint.
My symptoms did not improve and my surgeon kept insisting that it was due to GH osteoarthritis. I decided to switch to a different practice and surgeon who ordered a new MRI in April 2016. He identified a joint effusion of the synovium and diagnosed possible synovial chondramatosis which required a second surgery.
- Summer of 2016 was my second surgery where the new surgeon performed an additional subacromial decompression, bursectomy, and full synovectomy. Surgery photos showed pieces of cartilage growing out of the synovial wall suggesting his diagnosis of primary synovial chondramatosis was likely correct.
The second surgery and radiograms also verified that my glenoid cartilage health is very good and my overall joint space is fine implying that most of my pain and symptoms are tendinopathy related rather than osteoarthritis related. An MRI from last March shows no significant recurrence of loose bodies and a very recent ultrasound confirmed tendinosis of the suprapinatus that appears to be relatively mild to the radiologist. His report didn’t mention my supraspinatus but it’s not clear if it was because it looked good or because he didn’t look at it at all. My MRIs always showed less inflammation of my supraspinatus tendon compared to my infraspinatus tendon, so this is somewhat surprising.
In terms of PT narratives I was told that 1. band and light dumbbell work targeted to the cuff and scapular mechanics would rehab the issue (standard PT narrative) or that 2. SS-style strength training in the form of gradually heavier overhead presses and chins would rehab it. I feel the latter narrative may have slightly more utility for me given my goals but that my SS coach didn’t provide adequate instruction on how to interpret symptoms or to properly progress especially in the context of how the other heavy lifts like squat and deadlift might interact/interfere with the rehab. Also coach D did not emphasize HSR or any other protocol details. In terms of any pain or symptoms I felt, coach D never seemed too concerned with it provided I didn’t experience it during the weight lifting session. He also described any symptoms I experienced as “tendon irritation” and provided insufficient detail on how I should expect this should change (improve) over time.
Finally I will say that my symptoms are improving with reduced overall loads HSR-style specifically on my upper body lifts. I’ve also reduced the intensity of my deadlifts, which has somewhat detrained from a belted PR of 395x5 over time. My squats are pretty good where I am able to execute 2-3 belted sets of 5 at 315 at RPE no greater than 9 on my heavy day once per week.
I am interested in potentially working with you if think you can help me in the areas I mentioned, specifically in the areas of programming, properly interpreting symptoms, properly setting expectations, and how to properly train my squats and deadlifts around the injury to prevent too much detraining of my strength. Also my focus will be on rehab of the cuff and gradually increasing strength and functionality of my upper body lifts, not on new squat/deadlift PRs during this time unless they are in line with rehab methodology. My ability to work with you might be constrained by budget so we will need to negotiate a price based on services and see if it will work for both of us. Please let me know.
Thanks,
-Jeff
Hey Jeff,
Thanks for the details. It sounds like you are on the right track with adjusting loading and modifying exercises accordingly.
I believe it is important that we realize symptoms are not strongly correlated to tissue “abnormalities”. We have solid data on the findings you describe in asymptomatic and symptomatic populations. See: Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults - PubMed. This muddies the water to look at imaging and conclusively state that’s why you experienced the symptoms you did. We have even more evidence on the lack of efficacy for Subacromial decompression surgeries given they’ve been repeatedly demonstrated to be no better than placebo (Austin, Derek, and I will be releasing a rather in-depth discussion of the shoulder soon). There’s really no sense in harping on these surgeries though because what’s done is done. With that said, moving forward I’d recommend working with someone to help manage expectations, the process of meeting your individualistic goals, and instilling learned behaviors for dealing with the issue. It’s also important to understand that pain is complex and it is unlikely someone experiences pain because they weren’t completing this one exercise or from another standpoint are in pain because they’re under exercised. Happy to discuss. If you complete the questionnaire at the above linked website, then we can discuss getting someone to work with you remotely. Overall, sounds like you are doing quite well with progress!
Thanks Mike. I listened to the entire podcast you pointed me to and it’s excellent. I am going to share it with my friends. It turns out it was published exactly one year ago today!! It actually answers a lot of my questions and a hell of a lot more. It’s very interesting and if I weren’t already paid well as a software engineer with 20+ years of experience, a research career in anatomy and physiology might be very rewarding. I think the only thing I’m still unclear about is the degenerative process and understanding how to know if what I’m doing is contributing to it or not. During sessions with my surgeon he’d notice snapping and crackling in my shoulder which he describes as generalized Paratenonitis. If I understood him correctly, this sensation is correlated with general inflammation and a degenerative process, and he cautioned me to try and avoid experiencing this phenomenon. I’m not sure if this is a cause or otherwise correlated with the nociception and pain. I’ve read some of Dr. Baraki’s popular articles on pain and have come to the understanding that outside of quality of life concerns, pain in and of itself is not always something to be overly concerned about especially when it’s possible that chronic neural pain pathways have been conditioned to overreact. However I need some metric to understand when I’m still overreaching and potentially making my degenerative condition worse rather than moving it in a positive direction.
I found the end of the podcast to be very useful specifically the discussions around frequency and intensity, as well as the discussion of weight lifters and how they already tend to apply some of the heavy loading principles as a natural matter of their training. I think I’m going to take from the discussion on the collagen breakdown/synthesis timeline that I should probably go back to a 3 times per week lifting schedule and just titrate down my deadlift (and perhaps squat) intensities as they may in totality be applying too much stress to the recovering tendon. I’m also going to ensure that I apply HSR with RPE 7-8 intensities on my upper body lifts. What remains to determine is a workable number of exercises, reps, and sets per session to use in this model. I’m thinking for exercises presses (bench and overhead) as well as barbell rows and band assisted chins will be very useful for applying stresses to my cuff tendons consistent with the qualitative types of stresses they will be experiencing once I return to full intensities and volumes.
I plan to fill out the questionnaire to see if I can start the process of getting help with all this. Are you personally one of the people I might end up working with?
Best regards,
-Jeff
Sorry but I just saw this reply. I did 12 weeks of rehab with Dr Ray and it was excellent. I still occasionally get some shoulder pain, but the intensity of the pain is way down even though the intensity of training on my upper body lifts is way up. I finally feel like I can train my shoulders with normal intensity, frequency, and volume.
I highly recommend Dr. Ray and I would say that the most important thing I got from working with him was education and the confidence that I was not “broken”. I came to clearly understand that I was not destroying or damaging my shoulder with responsible programming despite the occasional pain and discomfort.
I hope this helps and sorry again for the late reply.
Cheers,
-Jeff
1 Like