Question
Hello, Dr. Leatherman,

I have pain in my shoulder, but from what I抳e read, I don抰 think it is the rotator cuff.  I am 39 years old.  I am in pretty good physical condition as I have maintained a good balance between weight training, cardio training and healthy eating.  I restrict my diet to only whole grains, lots of fish and greens, lots of water or decaf, sugarless tea and I don抰 drink or smoke.  I have been weight lifting for years, so I know something about gradually increasing weight over time and also a little something about not focusing on one or some muscle groups too much because this will causing other less developed groups to become strained or cause strains at times.  I obviously don抰 know enough, though.  I have developed a pain in my right shoulder.  It began three months ago after I had switched up my routine a little.  I had done a few short sets of behind the head military presses. I was not using a lot of weight, probably about 85 lbs.   I did not feel any pain during the exercise, but just after the exercise, there was just a small amount of tenderness in the lower halves of the Mid and Anterior deltoid muscle in my right arm.  A week later, after not exercising at all, my arm became very sore there; to the point in fact that I could hardly raise it above half way.  The pain had all but left in a week and a half, but persists to this day.  I have full range of motion, but a very slight pain when raising my arm laterally from my side or straight out in front of me.  However, the pain increases when I do standard military presses and bench presses.  I am used to benching 3 sets of 225 at 10 reps easily with little to no pain and no loss of strength.  Now I feel strong enough to increase the weight, but when I go up even as little as 10 lbs, I begin to feel the pain sharply and a little loss of strength due to the pain.  Of course, the higher the weight, the sharper the pain.  The pain will be uncomfortable for a day or two then return to being barely noticeable until I put strain on it again.  Is this indeed rotator cuff?  What do you think, and what can I do to rid myself of the pain so I can get back to a normal routine of lifting?

Thanks,
Jeff  

Answer
Dear Jeff,

Your suspicions are correct...this is not a rotator cuff tear per say, concerning the muscle bellies, but may be inflammation and strain of the main tendon. A quick explanation of the area:  A rotator cuff tear is a common cause of pain and disability in the adult population. The rotator cuff is made up of four muscles and their tendons. These combine to form a "cuff" over the upper end of the arm (head of the humerus).

The four muscles - supraspinatus, infraspinatus, subscapularis, and teres minor - originate from the(scapula), and together form a SINGLE TENDON UNIT. This inserts on the greater tuberosity of the humerus (lateral aspect of the upper arm.) The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint. The most common area to have a tear is in the supraspinatus, but your pain as described is comming from the lateral deltoid, some anterior deltoid, and probably from that single tendon unit.

The first thing you need to do is stop performing military presses.  This exercise is horrible for the shoulder and does more harm than good.  Replace it with an inclined bench press at about 65-70 degrees of incline.  This will still target the deltoids as well as the pecs.  Lateral deltoid raises and reverse flyes (or reverse pec dec) will work the lateral and posterior head of the deltiods.  From the workouts you have described, you are placing too much demand on the front of the shoulder while simultaneously causing impingement to the joint. You have most likely created an imbalance to the shoulder and need to correct it by concentrating more on the rear deltoids. You are lucky that you are only having muscle pain at this point, and I hope that you have not created any internal subclinical derangement of the joint.  If you insist on doing overhead presses, use dumbells as they require balance and the stability of additional muscles, and are less likely to result in impingement.

Now in contrast, it is important to do some focused training of the rotator cuff, because these muscle are what creates stability of the shoulder joint, and they need to be balanced.  The activities that you need to perform are internal rotation, external rotation, abduction and adduction of the shoulder.  The first step is to let your arm hang with a one or two lb dumbell in your hand and do circles...do it in both directions. Thes are called pendulum exercises.  Next you can progress to actual resistance against gravity in a specific plane.  Two to five lb dumbells max.  Elbow should be pinned close to your side and movement slow and deliberate. Then you can progress to a more complex movement such as arm abduction with a straight elbow.  Here is a link to a good website that has illustrations for you to download/consider:  http://familydoctor.org/265.xml

Lastly, we have to consider the possible role of nerve root irritation of the C5 nerve root.  This is the nerve root that supplies sensation and function to the deltoid muscles. It also supplies information to the bicep which you have not mentioned.  It is still possible to have dysfunction at that level, which may be responsible or contributory to your symptoms. From your descriptions, t is most likely that the pain is being generated locally rather than at the spinal nerve, but the only way to tell is to get a good orthopedic evaluation of the joint with provacative testing, deep tendon reflexes, and a radiographic view of the cervical spine called an oblique projection if exam findings warrant.  Your local chiropractic physcian is well trained in these types of examinations, and I would recommend it if you have any further problems.

Hope this creates a better level of understanding Jeff.  Let me know if you have any further questions.  

P.S.  Concerning your training, compound movements such as the squat, squat press, and olympic presses such as the two handed snatch, the two handed jerk, and the clean and jerk are vastly superior at building strength and muscle mass, but your core must be strong before attempt these lifts, and your form must be perfect.  I would strongly suggest that your consult with a CSCS certified instructor before trying these lifts on your own, and then incorporate them into your workout as your base when perfected. check out the National Strength and Conditioning Association at, www.nsca-lift.org


Respectfully,
Dr. J. Shawn Leatherman