Friday, August 2, 2013

Shoulder Health and Crossfit

I recently started working out at a Crossfit gym. I have always loved Olympic and multi-joint lifts as a way to work out, so logically moving into Crossfit was the next step. Crossfit offers some of the best and most exhausting workouts I have ever had. The class atmosphere in addition to the intense training is great and unlike any other fitness "class" you can take at a chain gym. One week into doing crossfit I noticed the lack of posterior deltoid work and proper rotator cuff/external rotation exercises. It dawned on me, after seeing a couple of [Crossfit] patients with shoulder issues (AC joint issues related to rear deltoid/anterior deltoid imbalance) that this could be an issue with Crossfit. At the same time a very easy and adaptable fix.

Presses, pull-ups, push-ups, snatch, and all the variations of pushing weight above the head all strengthen the flexors. As in, the pecoralis muscles (specifically the clavicular division), the anterior deltoid, along with the legs, core, and back as stabilizers. Don't get me wrong, Crossfit works the back muscles extensively, but one thing to note;  pull-ups, butterfly pull-ups, and any other variation primarily work the latissimus dorsi group. The latissimus dorsi muscle is an internal rotator of the shoulder. Therefore, external rotation is excluded.

In this article I will be covering the top 4 musculoskeletal injuries to the shoulder that I see in my clinic. I will also cover and talk about ways to strengthen the shoulders and rotator cuff muscles in order to take you to the next level at Crossfit, or any other workout you are doing.

Top 4 Causes of Shoulder Problems (seen in my office)

1. The Neck: If the neck is out of alignment this can have a devastating effect on the shoulder. If you look up the maps of the cervical plexus (and while your there look up the brachial plexus) you will see the cervical nerve roots. It is these very nerves that innervate the arm muscles. Now the specifics aren't needed for this. What you need to know is if the neck is imbalanced, that can place pressure on the nerves. Proper nerve function is needed for muscles to activate and function properly. If the neck is off, the arm muscles can be off, and this includes any one of the many different muscles acting on the shoulder. Imbalance leads to dysfunction and pain. This is the primary starting point. Any of the following injuries can stem from the neck so ALWAYS CHECK THE NECK.

2. AC Joint (M/C Crossfit imbalance): Before we get into the actual AC joint we need to look at the deltoid. The deltoid is the muscle that covers the whole shoulder. It is also notoriously weak in people. The unique thing about the deltoid is it antagonizes itself. That means when the anterior deltoid is firing the posterior deltoid is not and vice versa. Another example of muscles that antagonize each other are the biceps and triceps. When you flex your bicep you can't flex your triceps. It is turned off. Now the deltoid is unique in that it does this with itself. When using Applied Kinesiolgy (neurologic testing) I find that when a muscle is spasmed or chronically tightened (muscle fibers shortened) it can inhibit the muscle opposing/antagonizing it. The 2 most common are the anterior deltoid being over tight and shutting off the rear deltoid, and the psoas muscle being over tight and shutting off the glut max. (Interestingly both are ball and socket joints.)

What does this have to do with the AC joint? Everything! The rear deltoid muscle stabilizes the AC joint. So think about it. The anterior deltoid is chronically tight, there is a strength imbalance in the deltoid due to presses and internal shoulder rotation exercises. The rear deltoid is weak and inhibited. Where does that stress from the imbalances go? The AC joint. If this problem persists for too long the stress can become too great and a diagnosable AC injury or separation occurs.

3. Biceps Tendon Injuries: This is a fairly complex condition, often called biceps tendonitis among other things by medical doctors, that can affect a number of different joints from the neck to the wrist and can be hard to find if you don't see someone who uses Applied Kinesiology. Applied Kinesiology is neurologic testing. It test muscles and how well the brain turns them on. If a muscle is turned off, or not firing at full potential, it leads to imbalance. Imbalance leads to pain and dysfunction and eventually serious injury. In terms of the biceps tendon, I am talking specifically about the long head biceps tendon.

Some anatomy about this injury you need to know to fully understand the injury includes the bicipital groove of the humerus, the subscapularis, the long head of the biceps, and surrounding musculature. If you don't know these structures please look them up. The long head of the biceps moves up the arm and attaches to the glenoid labrum. The problem mostly arrises in the area of the the bicipital groove. This is a valley in the humerus which houses the biceps tendon. Simply stated, irritation happens to this area and the tendon moves medially. The subscapularis is an internal rotator of the shoulder. It attaches to the transverse ligament, which is the ligament that houses the bicipital groove holding the biceps tendon in place.

The problem: As we slouch, have too much focus on internal rotation of the shoulder, weak extensors, etc. the subscapularis will tighten and create a lot of strain on the transverse ligament of the bicipital groove. This is turn puts strain on the biceps tendon and the biceps function as a whole. This leads to major imbalances in the shoulder and elbow. The shoulder, being a more mobile and vulnerable joint, bares most of the stress and becomes injured.

Sounds complicated, but treatment is usually pretty straight forward (at least in my office). Identify what is happening with the muscles. Which are inhibited, which aren't. Work on the joint specifically, the subscapularis, the bicipital groove area, and long head of the biceps (specific treatments) and things generally get better almost immediately. It isn't rocket science!!! (As in, your doctor should know how to treat this. If they don't, FIND A NEW DOCTOR!)

4. Infraspinatus injury: The infraspinatus muscle is one of the main external rotators of the shoulder. This muscle is notorious for becoming injured, and I believe it is because of the heavy amount of internal rotation today's life and workouts require. This muscle has to be addressed in all shoulder injuries for the shoulder to become function. That usually entails muscle work, muscle lengthening, and neck adjustments. If you don't address an infraspinatus injury, the shoulder will NOT get better.

You may be thinking what about the supraspinatus tendon. This is a common shoulder injury. This is the result of years of wear and tear (really major imbalance and dysfunction) culminating in the tendon tearing. I am not a surgeon and don't see supraspinatus tears in my office. I do have patients with them and miraculously some of them have skipped surgery and have better shoulder function after seeing me. This is because when the shoulder is balanced, there is no added stress on the ligaments and joints, and things heal.

Now, to the good stuff. What can you do to work out the shoulder to take your Crossfit workout to the next level (or any workout for that matter)?

The posture stretch: Take a 3 foot foam roller. Lay on it so your whole spine is on top of the roller. Pelvis to head. Lay your arms on the ground, thumbs pointed toward your head, at a 45 degree angle. Feel the stretch and inch your hands up over the course of 15 minutes. Do this everyday until you no longer feel an intense stretch with your hands at 90 degrees or greater. (hint: should look like a cross position.)

Rotator cuff workout:
Can be done as a workout by itself or after a workout.

A1: 30 degree incline prone trap raise 3 x 10-12 (3 second eccentric phase) 10 sec rest
A2: Elbow on knee DB external rotation 3 x 10-12 (3 second eccentric phase) 10 sec rest
A3: Low pulley external rotation at 30 degress 3 x 10-12 (second eccentric phase) 60 sec rest

This is a super set workout. For more info on what this means, eccentric phase, timing and any lifting questions I encourage you to visit charlespoliquin.com for more info. Below is the link to the article I took this workout from.

http://www.charlespoliquin.com/ArticlesMultimedia/Articles/Article/984/How_to_Square_Round_Shoulders.aspx

Posterior Deltoid workout:
The rear delts should be worked on a minimum of once a week. I like to to the same as the rotator cuff and follow with some super sets after a workout. It should be noted that shoulders can be a whole day at the gym themselves, and I personally have been working shoulders out extensively for years. So you may have to have separate shoulder days for a while in order to do this.

A1: Bent over rows 3 x 6-8 (2 second eccentric phase) 10 sec rest
A2: Standing cable rows 3 x 8-10 (2 second eccentric phase) 10 sec rest
A3: Face Pulls with rope 3 x 10-12 (4 sec eccentric phase) 60 sec rest

It should be noted that I have adapted these workouts from the shoulder workouts of Charles Poliquin. That guy knows his stuff and for more reading check out his site.

This article has been fun for me to write and I hope very informative for you all. With the tips here, all you Crossfitters out there looking to take your lifts to the next level think about shoulder health and strength. Some added effort can make huge gains and even break some PRs along the way.

Cheers,

Dr. Kurt

References:

Netter FH. Atlas of Human Anatomy. 4th Ed. 2006. (Textbook)

Rakowski Bob. Kinesiology Applied to Functional Medicine. Seminar Series 2010-2012. Minneapolis MN. (itsdrbob.com is his website) (favorite teacher/seminar instructor/mentor/doctor check his seminars and info out!)

Charles Poliquin. www.charlespoliquin.com (too many articles to list. One of the best sources of info I have ever come across. Check out his website.)

http://www.charlespoliquin.com/ArticlesMultimedia/Articles/Article/962/Building_3D_Shoulders.aspx


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