I am a 30y/o male with acute on chronic shoulder injury/issues with DJD. In 2003, I had an initial snowboarding injury to my left shoulder which was repaired. I have since had many dislocations and reductions since. I have consistently been training since 20012 aside from occasional 1-2 weeks stop for vacation or minor injury. I have not had any instability in my shoulder for at least 10 years. My ROM has drastically decreased and my pain has significantly increased. Almost any pushing or pulling motion, particularly vertical, will aggravate my shoulder. Some times I make it 2-3 weeks in a program without any issues and then one week, I am almost unable to pull my pants up to my waist from the floor. I finally got seen by an Orthopedic surgeon. I was informed that the loose bodies and arthritis are primary source of pain. March 19th, I am scheduled to have an Extensive Arthroscopic Debridement with Open Debridement of Biceps Tendon Sheath.
XRay Read: 1. Degenerative changes of the left shoulder joint with Hill-Saschs deformity and likely Bankart lesion (better seen on MRI of left shoulder)
2. Dystrophic calcification adjacent to the left shoulder joint, may be related to repetitive dislocation or tendinopathy MRI: 1. Prior anterior shoulder dislocation with old Hill-Sachs and bony Bankart deformity. There is detachment of the anterior labrum.
2. Biceps, Supraspinatus and Infraspinatus tendinopathy
3. Moderate glenohumeral osteoarthritis. Subchondral cysts are seen within the greater tuberosity with marginal spurring of the humeral head. There is full-thickness cartilage loss along the glenoid with subchondral cysts of the glenoid.
4. Moderate size joint effusion containing many loose bodies of varying sizes that communicates with fluid surrounding the proximal biceps tendon. Additional loose bodies within the axillary recess. No significant T2 signal loss. Findings consistent with secondary osteochondromatosis
I have every intention of going through a full rehabilitation phase and am not rushing to return to weight training. I was told that I should lift after rehab but “do not lift heavy”. I do not know what that means because “heavy” is relative to the individual. I am by nature a powerlifter but do not have to continue down that road if it will be detrimental to my shoulder health. Another Orthopedist in the group said “if it hurts, don’t do it”. I understand that a little more than the “don’t lift heavy” recommendation. I was also encouraged by a Chiropractor that goes to my gym and is a powerlifter to avoid overhead motions if possible and to do incline and flap pressing instead.
All this to say, what training considerations should I take moving forward in regards to training with my shoulder?
Thanks for your question. Sounds like you’ve been through quite a lot with your shoulder in the past. I assume you’ve worked with a physical therapist before?
I actually think you will have a better long-term outcome from post-operative rehabilitation if you receive some pain neuroscience education. To what extent are your familiar with our / others’ work in this area?
I am familiar with some of your lectures and podcasts on pain. I’m not concerned with the pain. I have worked through and around the pain for years and still make sure I get my training in. With good form squatting 405, DL 535 and Bench 275 paused. Also weighted pull ups with 45lbs and a hammer strength row with 150ish pounds. I used to be able to overhead squat and also press but am unable to do either. An incline press and an SSB Squat is what I am down to now bc of pain and ROM. I plan to have the operation and rehab it appropriately. I dont want to rush back under the bar of take any short cuts at all. Im all about the long game.
My greater concern is how conservative or limited of an approach to training should I take. My surgeons are sports medicine guys and take care of the Memphis Tigers football team and the Redbirds (St Louis Cardinals AAA baseball team). However they have given me very vague recommendations about not training “heavy”. They both mentioned that I am looking at a shoulder replacement down the road and that I want to prolong that as long as possible. Like many physicians, they dont have an appreciation for training nor do that understand my passion to lift, even if not competitively. On the other hand, i don’t want to speed up the degenerative process. My longevity in the sport and overall health is most important.
Are there any strong suggestions to guide my training like avoid training overhead or avoid training with a weight heavier than 225 or 315 on bench or press or should I stay in the 10RM or 12RM weight ranges and avoid the heavier 3RM-6RM stuff. Or should I simply avoid anything that causes pain but I can train as heavy as I can tolerate pain free? I’m searching for something tangible that can guide my training more so than “don’t lift anything heavy” or the worst was “dont do anything that hurts” bc i can find a way to modify something that may not be good for my shoulder health not hurt.
I agree that “don’t lift heavy” is vague and unhelpful. With that said, there are certainly no strong recommendations (at least, any that are based on evidence) regarding avoiding training overhead, or avoiding an arbitrary weight threshold or rep range.
If you have this history of repeated traumatic injury to the shoulder, you’re going to have radiographic osteoarthritis. But that doesn’t necessarily mean you have to be in pain for the rest of your life. And I would not agree that you are in any way guaranteed to need a shoulder replacement.
When it comes to joint OA, the evidence shows that fear and subsequent inactivity result in worse long-term pain and functional outcomes, which then results in more “degeneration”. So, you must train - but, as you suspect, there is no need to be overly aggressive about it. Follow the post-operative rehab plan, and a conservative, gradual loading/training strategy beyond that would be wise. The Starting Strength video on post-operative shoulder rehab is quite good. If I were in that situation, once I started pressing I would certainly avoid grinding really hard reps, and probably avoid anything over about RPE 8, at least for a very long time. Of course, it should similarly be noted that the details of these recommendations are not based on evidence either.
I really appreciate the time you have spent on this thread and helping me develop a post-operative plan. I understand those recommendations arent evidence based, however, I do feel that experience and the intuition of someone both medically trained and who has put years in the iron game is valuable. I highly regard science but I also realize, science doesnt always have the entire picture which is where a combination of experience and science has the most to offer.
My intuition said something similar to what you have advised was probably where the truth would lie. Somewhat of a moderate approach between giving up strength training and pushing the envelope. I am not afraid to train and I know that movement is the key to less pain in OA. Regardless of pain with OA (I acknowledge there will likely be some and I embrace that as a part of my life) I do not intend to give up training nor will I allow it to be a crutch or an excuse. I did not allow myself to be nocebo’d (sp) despite being told my shoulder was 'that of a 74 year old". I have heard your talks about that and due to my nature, I refused to just accept that and give up. It was only a matter of optimizing my training for MYSELF and my situation. I will definitely check out the starting strength video about post-op shoulder rehab. I also appreciate the recommendation of sticking to a roughly RPE 8 and not grinding any reps which fell in line with what I would interpret “not lifting heavy” to mean. I do appreciate the recommendation to keep vertical pushing and pulling in the routine since there isnt any evidence showing it to be unhealthy for me. That was the one thing I was considering eliminating or minimizing.
Correct me if this is not good advice but the one helpful thing I was given that I feel was reasonable advice was to avoid doing things that “cause pain”. I don’t mean getting sore or some discomfort but true pain like when I couldnt physically pull my pants up with my bad arm the day following a workout.
Lastly, I also had feelings that this doesnt mean that I will have to have a shoulder replacement but part of that is just me refusing to be inactive and me being hard headed, not bc I have some evidence or literature to support me. I will do everything to optimize my health and shoulder that is within my power to avoid something like that. What I dont understand is what exactly you mean by “if you have a history of repeated traumatic injury to the shoulder, you’re going to have radiographic osteoarthritis. But that doesn’t necessarily mean you have to be in pain for the rest of your life”. I am a registered nurse with years of level 1 trauma ED/ICU experience and understand what radiographic OA is but how is that different when it is caused by repeated trauma as opposed to age/degeneration?
I’m also not exactly clear on what you’re asking here. It really isn’t all that different – radiographic evidence of OA is very common in both situations, but correlates poorly with pain, as I suspect you know.
My surgeon has instructed basically immobilization for 1 week. Initially they had planned to start rehab POD3 but now he said immobilize until a POD7 follow up. If I had a Biceps Tenodesis, would it be unwise to follow the SS post surgical shoulder rehab you referred me to?