Shoulder pain linked to posterior chain and shoulder blade weakness

Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales. And thanks for joining into the podcast. This one is actually a call-in podcast today. And it's funny. Actually, it's not a call-in. It's when I was recording a podcast earlier today, I shut the door to my house. I used to do it in my house now. And the neighbor comes walking up. And the neighbor, I'll leave his name out.

But it's funny. He tends to see me sometimes. Like, when I'm walking up, he'll be out his window. And it's funny. We have, like, an ongoing thing about him in the neighborhood. It's like, he knows when you're around, he'll jump out there, and he'll sneak up on you. And all of a sudden, he'll start talking to you. And he's the friendliest guy. But anyways, so I was doing the podcast on a different topic. And he pops in, and he started asking me about his condition. And we'd been texting a little bit about it before. So he doesn't let on everything that he wanted to talk about. But this is, I had him record what his question was. So here it is.

So getting a lot of pain in my left shoulder really bothers me when I'm surfing, when I'm rock climbing. Then the pain kind of radiates from my shoulder down to my elbow. Help me. How do I fix it? So what we have going on here is, what he hasn't really said, or I know a past history of what's going on with him as well, is that he had a past knee injury, a past ACL injury, as well as a past hamstring tear that he hadn't spoken about. But actually, he came and lifted one day with me at my office. And, you know, it was just a regular, like, bro sesh to go in there and just kind of start throwing weights around and stuff. And he's actually a trainer himself, too.

So he's in there squatting. And I saw so much low back round, or the slang term is called butt wink. The low back just rounded into flexion, where I, you know, I had, I couldn't ignore it. I had to coach him out of it. So I said, I brought his attention to it. He corrected it. He actually has really, really good flexibility and mobility. He squat deeper than most people I know. And he was able to correct it, which makes me think And I think that his issue with squatting wasn't really a mobility or flexibility issue was the fact that whether he can control that or not, or a strength issue. And the reason why I'm bringing this up is because that everything I've known about in the past, he's talked about, you know, his shoulder blade condition, it seems like one side, one shoulder is kind of more forward than another. And it seems like it's affecting his lifts, because he does like to do a lot of Olympic lifting.

And now he's talking about all this other stuff. And I, he wanted some recommendations of isolated things to do in the wrist, in the elbow, in the shoulder to remedy the sensations that he's feeling. And I keep thinking back to everything that I've seen on him before. It looks like his shoulder blade was kind of, you know, popping out a little bit. Like he said, he hasn't been lifting or dead lifting or working his posterior chain or backside, his hamstrings, his glutes, his spinal rectors, as much as he had been prior to the ACL injury. And then he, now he brought up the hamstring thing or the past injury. And I see that his squatting is a little suspect.

So I, I, I stopped him. I was like, look, is, is your shoulder, is your, is your shoulder condition? Do you think your shoulder condition is connected? I mean, it has to be connected to the body. What have we found in the past with you? And he basically says, you know, like, well, he has a wing and scapula and so on. I'm like, okay, so it's a backside issue right there. And I'm like, I can give you some stuff for like the elbow and the wrist and so on, but it's, it's more of like a local fix, you know, like it, it fixes things right across head joint. But we all know that, and he knows too, that it's, it's just, um, they're just kind of conditions that pop up when you have, uh, movement abnormalities or things aren't stuck on the body as well as they should be, or, you know, in proper squat position or whatever.

Um, a good example is with the knee. Uh, we all kind of know that the knee is a, it's a condition of improper stacking. Um, I think I've said it before, but the knee is called the redheaded stepchild of the lower extremity. It's never its fault, but everyone blames it. And a lot of times we have to look at the trunk and the hip to make sure those are working well. So the shoulder girdle or the, the shoulder is kind of the same way. Um, the shoulder itself, the rotator cuff is really, really correlated to, um, shoulder blade function. And there's a whole large topic I can go into with shoulder blade function, but for the most part, let's just say, um, is it doing its job well?

Because the shoulder blades only held on with one bony attachment and that's in the front and a lot of shoulder pain, actually, no matter what it is, labral tears, um, rotator cuff tears or tendinosis, uh, bursitis is, they all kind of present the same spot, which is in the front where he kind of pointed at when he did this recording for me. So I keep thinking on the backside, you got stuff going on on the backside, you know, and so what else is there in combination with the backside here? Well, you haven't been really lifting that much and your squatting technique showed demonstrated weakness on the backside because he was rounding forward.

So the spinal erectors or the muscles that go up and down the spine in regards to strength, endurance, can the whole position or so on was suspect as well. And that'll go hand in hand with that shoulder blade, which will go hand in hand with the rotator cuff and the whole arm as a unit, right? So then we started talking more about, again, the deadlifting, like when's the last time you've deadlifted? And he was saying it's been, I mean, it's been before his, his, his knee injury or his knee repair. So it was over a year and strength gains. Actually, strength has been showed to decrease about four times as fast as you can gain it.

So if he hasn't been using that that much, let's just say he's been on bed rest for, he hasn't been on bed rest, but, uh, for all you just, it'll make it easier, uh, to kind of understand. If you take one week of bed rest, it'll take four weeks to regain that strength that you lost when you're on bed rest. So he hasn't been really training that pattern, um, with, uh, deadlifting or RDLs or anything of that nature. So he's kind of lost, I mean, he's lost, let's just say not even a year. He's lost, say, like six months worth because I know he's been doing some stuff. So it'll take another four times that amount to bring it back, right?

So he was here today talking about, you know, how frustrating it is. He can't surf, you know, without feeling the pain and so on. And, um, it seems like it's getting worse and it's very frustrating. I can tell it was very frustrating to him. And so I just looked at him and I was like, look, do you, you, you wanted, you don't want to do this rehab or like, have you been doing the rehab? And he said, yeah, I've been doing some, he's been doing some shoulder blade stuff that we'd talked about, you know, months and months ago. And I said, do you know how long it usually takes according to research to really make a distinctive change or something measurable?

And I said, most research studies are 12 weeks, 16 weeks. I'm like, it takes some time. It takes a lot of time, you know? So I could tell he was frustrated and it was getting, starting to get worse. So I kept bringing him back to you. I said, well, someone with a hamstring injury like you've had, would it be also suspect that they wouldn't have a lot of posterior chain strength? He's like, yeah. I said, okay, I'm like, have you been deadlifting? Is it suspect that someone who hasn't been deadlifting also has posterior chain weakness? Well, yeah. Okay. So shoulder girdle stuff or shoulder stuff, isn't it correlated to have shoulder blade dysfunction or shoulder blade strength with rotator cuff conditions?

And he said, yeah. So I'm like, look, we keep going round and round about what types of exercises or rehab or treatments will be helpful for your elbow, your wrist, your shoulder, and all these different spots in isolation. But we're ignoring the large thing here. I'm like, I know you don't want to do it. I'm like, do you like doing it? He's like, no. He's like, deadlifting and RDLs. He's like, they're boring. They're really boring. And I know he likes doing Olympic lifting, surfing, all this stuff. And I totally get it. It's boring. But I think the take home here is that you've got to ask yourself the reason why you're doing what you're doing at the gym or for rehab.

Are you doing it because you just love rehab? Are you doing it because you just love doing deadlifts? Because, I mean, that is a sport. Lifting is a sport. People love doing it. But if you don't love doing it, ask yourself the reasons why you're doing it. Well, it's to rehab your shoulder or your knee. In this case, the shoulder. Well, why does he want to do it for the shoulder? Because he wants to surf. He wants to do Olympic lifting. But he doesn't like doing the other parts. And that's totally fine. But if you want to do the other things, you have to be responsible with your body, strengthen it, and make it function well so you can enjoy yourself while you're doing the other things.

So he ended up leaving after that. And, you know, that's kind of just the take home. I really, really hope he works on the elephant in the room because I think with all those conditions combined, the major factor that I'm seeing and based upon his history is that he could build up some posterior chain strength. And posterior chain, again, so for those of you who don't know, it's the spinal erectors or everything on the backside of the body. So the ones I like to talk about are the spinal erectors, which are the muscles that go up and down the spine. And they can go all the way from the low back all the way up into the skull.

That's the whole backside. And we have the shoulder girdle, which holds the shoulder onto the body. And we have the gluteal muscles and we have the hamstrings. OK, all this is really, really important for his case, I believe, at least because we want to leave every stone kind of we want to leave it unturned. And I did send him a great research article by Kibler, which I can put in the references somewhere here so you guys can access some of the good research on shoulder stuff. And this was for shoulder stabilization or rehab for pitchers or throwing shoulders. But I strongly discourage doing all of that in isolation.

I'm like, you can get lost. You get lost in how many rehab exercises there are for only a shoulder. And I scrolled through it with him. And it's a 50-page article. And I want to say the last 20 pages are their phases of rehab exercises that we would do with this thrower. And I'm like, look, you're not throwing a baseball. You're not doing anything nuts with your shoulder that has more of a whipping effect. So why don't you just use the hardest three or four? And I know that a shoulder rehab specialist might just cringe at me saying this. But, you know, I think of it more of that we want to make sure that we can ensure success with these people.

Because they don't – he didn't want to do it anyways. If I can get him to do four of the most challenging things that are not duplicating each other within a day, I think I'm winning with this guy. And what I mean by not duplicating the same thing is perhaps our goal is to work the serratus interior, which – by the way, these are all shoulder blade muscles. Serratus interior, the – let's just say lower trap, middle trap. Let's just – let's just use those three. So I would rather pick exercises that would isolate or that would use predominantly one of those three muscles per exercise. So if we're looking at like a serratus push-up, we're going to get the serratus interior.

We might not isolate into the other stuff like the lower trap and middle trap, but I don't want to do a serratus push-up and then plus push-ups plus then a serratus punch or an overhead shrug because those are all kind of the same thing. I want to make sure that we're diversifying and spreading out this guy's rehab at least because we almost have to trick him into doing some of it and mix in some stuff that are fun. You know, if he likes doing Olympic lifting, perhaps we'll just do – we'll just do pulls, you know, pull drops, or as I call them. And I don't remember if he does snatches or cleans.

I think he's doing snatches. But I would really questionably want him to do snatches at all because if he has questionable shoulder stabilization, why do I want him to do that quickly overhead? Perhaps I would rather have him do something like a strict motion or like a pure strength motion overhead. Lighten the weight up and increase the reps so then he has control overhead rather than just catching it with an abrupt stopping point like he is in a snatch. But I'm okay with him doing the pull section. Just do snatch pulls. Pull it up. Let it drop. And that might make it sane enough, make him sane enough so he'll add in some of the rotator cuff stuff or the shoulder blade exercises all in the meantime.

And maybe do some core, some other posterior chain stuff, some RDLs, you know, stuff in a Roman chair, GHDs. And these are all stuff you can Google, by the way. But anyways, I thought I would share that with you guys because it was fresh in my mind. And he's actually a, I guess, a case that I haven't really managed hands on. You know, I see him in passing and we talk about theory of it and he's very educated about what he's doing already. But sometimes you need a little bit of guidance. And I mean, I can easily tell him I want him to do, you know, a box squat and he'll know what it is. And he'll know how to cue other people into it.

But as soon as we get into him doing it, obviously, like we were working out in the gym that day, form can degrade. And I'm sure I had some form issues too. And sometimes you need someone else to help you coach through it because it's really hard to recognize what your body's doing if it's been doing it poorly for a while. And who knows how long he's been doing it that way. But either way, I thought I would share that with you guys because it's fresh in my mind. And it's a case that we're more talking in theory with things rather than actually showing hands-on exercise instruction with him. I have referred him to the online course for Rotator Cuff before, but now I see there's a lot more to it.

So I would probably refer him to some of the core strengthening program that we're putting together as well. And I would probably refer him to the squat video to make sure that he knows what I'm looking for and he can make it fresh in his mind. I'm sure he knows all the cues already, but sometimes hearing it in a different way is really, really helpful. So thanks for listening today, guys. But if you want to contact me, go to p2sportscare.com. p2sportscare.com is my main site. And I hope, I hope by the time this podcast airs that our website redesign has already finished because it has been a long, long time that I've been working on new content.

I've been trying to make it very, very up-to-date research and suggestions, self-help, and all that type of jazz on the site. And the complaint with the old site was actually that it was too busy. I'm trying to make it very easy. And we even put some athletes, types up there. Right now there's a baseball player, a runner, and a golfer up there. And we have hotspots on them. So you can just go on and click on your hotspot. And if you have a knee injury as a runner, you click on that, and it'll pop up as the top five, six, seven things that knee injury could be. Some suggestions, some education, and some rehab, some treatments, and so on.

We plan on building beyond this with some of the select cases that we really, really want to explore a little bit more. And we're going to make the online courses mainly on those. So you'll see links to the online courses in there off of the P2 Sports Care website if they've been selected as a case that we want to take on with an online program. I'm not saying I'm not going to do a lot more programs because I really, really do like making them. And it's just like this podcast. It's fun sharing, you know, information. And I just have to make sure that I'm not burying myself in doing too many courses and not doing the courses that I am putting on there well.

I want them to be the absolute best information you can find. I want to constantly update them, make sure that you guys have lifetime access to it and a library of exercises you can use. By the way, I said lifetime at this point, but I might change that. And it's not because I don't want to keep giving out the information, but I've actually found, and this is all a tangent to the, to obviously the case I was talking about. But I found that sometimes if you don't create urgency with people, just like kind of like homework in school, they don't do it. So I might not be doing any favors. So we might do a, might do a little bit of split testing to see if people respond better or they complete the course quicker if we put it as unlimited usage or just timeframe.

So anyways, but you'll see it up there. All the information will be up. So thanks for checking us out. Again, p2sportscare.com. If you want to be featured on the podcast, there should be a link to leave a podcast voicemail. You don't need a phone. You just click through your computer, talk to your computer, hit submit. That's it. And if it's very, very detailed and a case I think is interesting to, for everyone else to learn from, then I'm going to share it. So I'll talk to you guys soon. And thanks for listening.