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Old 02-22-2012, 07:13 AM   #10
charliefedererer's Avatar
Join Date: Feb 2009
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Originally Posted by Pacific lefty View Post
I never thought I'd be back on this forum so fast...I had my tendonitis/impingement well under control with my PT and after seven weeks I was ready to start hitting. I had one hitting session and on Jan 30 did some extremely light weighted lat pulldowns and sitting chest presses in gym. From that day on the pain was right back. Impossible to do any external rotation exercises, even isometric, or stretch arm across body. And even three weeks later it is still the same.

I can't believe I could have caused the problem to come straight back. My PT says that must mean that the impingement is so bad that I do need surgery. I just feel at the moment that I am never going to play competitive tennis again (not to mention having nightmares about crashing my car into a wall)...

So next week I am trying two things...accupuncture, and meeting the dreaded cortisone happy ortho. surgeon. Has anyone found accupuncture helpful? I guess I will probably have another mri to see exactly what is going on here..

Please anybody, a word of encouragment as I've been spending most of this week just reminding myself to keep breathing in and out...
You can definitely impinge your supraspinatus doing lat pull downs (and hopefully you weren't pulling the bar behind your head, where maximal impingement would occur.)

I'm not sure exactly what the sitting chest press was, but it also could have pinched the supsraspinatus, even if holding the dumbells the "right way":

"Wrong way" to hold dumbells because it positions the humeral head to maximize the potential for impingement.

"Right way" to hold dumbells to turn the humeral head so that impingement is minimized.

And certainly avoid machines where the pushing angles up:

References for future use (obviously too early to do any of these exercises now):
What Exercises Cause Shoulder Impingement? by Emma Roberts

"Contraindicated Exercises
Professional or recreational athletes with a history of shoulder instability, shoulder injuries, or pain and inflammation in the shoulder girdle need to avoid overhead and military presses, especially with a barbell; dumbbell side raises performed with thumbs pointing toward the floor, upright rows wherein the bar is lifted above the height of the shoulder, the incline bench press, and lat pull-downs with the bar placed behind the neck. Each of these exercises place inordinate stress on the shoulder and may cause impingement in vulnerable joints."

Pressing and the Overhead Athlete by Eric Cressey
"With respect to the glenohumeral joint—one of several articulations comprising the shoulder girdle—there are five different characteristics of any exercise that I take into account.

1. Traction versus approximation: Pull-ups and pull-downs (like most cable exercises) are an example of traction exercises. They pull the head of the humerus away from the glenoid fossa (shoulder socket). Conversely, pressing exercises are approximation exercises. They drive the humeral head into that socket. Approximation exercises increase the likelihood of rotator cuff impingement far more than traction, and this is why exercises like pull-downs, pull-ups, and shrugs can be integrated into rehabilitation programs before various presses. It also explains why many people with external impingement respond well to traction work with bands. They’re basically giving the rotator cuff tendons room to breath.

2. Adduction/extension versus abduction/flexion: Does the movement have the arm further away from the body (elevated) or close to the side? We know that an elbows-tucked (more adducted) bench press is much safer for the shoulders than an elbows out (abducted) style of bench pressing. The same can be said for overhead pressing (scapular plane versus frontal plane).

3. Closed-chain versus open-chain: Movements where the distal segment is fixed and the proximal segment is moving (closed-chain; e.g. push-ups) will always be safer for the shoulder than movements where we are stable proximally and moving distally (open-chain; e.g. Bench Press). For this reason, you’ll always be able to integrate push-up variations in a shoulder rehabilitation program before you move to barbell and dumbbell pressing variations. [note that Cressey's audience is largely heavy weight body builders/ahletes, so elastic bands and very light dumbells will likely be more appropriate for you than pushups eventually.]

4. Dumbbells versus barbells: We know that external rotation of the humerus repositions the humeral head and gives the rotator cuff tendons more room to “breath” without impingement as we elevate our arms. We also know that external rotation of the humerus ties in closely with forearm supination—just as internal rotation is associated with pronation.

A barbell fixes us in a pronated position so we’re locked into more of an internally rotated position. Dumbbells allow us to supinate a bit more. In turn, we are able to get more external rotation during the pressing motion, therefore protecting the rotator cuff a bit more than with barbells.

5. Isometric versus ballistic (and everything in between): It should come as no surprise that low velocity movements pose less injury risk than those performed ballistically. We don’t play sports at a snail’s pace, though, so it’s important that we prepare our athletes for the dynamic nature of their sports. However, we still need to recognize that isometric and lower velocity movements have merit in certain instances, especially if we’re looking to deload the athlete."

The good news is that you already have a couple of months of rehab therapy under your belt so you are not starting from square one. You are much more of an "expert" now on how to proceed in with your rehab.

But the bad news obviously is that pain/inflammation has recurred.

As pointed out above, a cortisone shot has the potential to turn off the inflammation. But at the expense of turning off healing of any small tear that may have occurred.

I don't think you have to consider yourself a failure of "conservative" therapy and therefore automatically need surgery. (Realise coming back from surgery could easily mean a year or more before getting back to serving/tennis.)

But I agree with the others above that the rehab therapy back will have to be slow, incremental, and not to be tempted to try new exercises without consulting with your therapist.

I know you are eager to get back to tennis. But while in Ireland, your preparations for THE big holiday should be taking precedence over tennis anyway.
So, how are your St. Patrick's Day preparations coming along?

Last edited by charliefedererer : 02-22-2012 at 07:26 AM.
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