Rock Magazine

Tim Macartney-Snape and his physio Lissanthea Taylor give us two perspectives on shoulder injuries.

The wounded warrior: Does anyone else have a recurring dream about discovering the perfect crag, complete with overhanging buttresses and flat, sandy fields of well-featured boulders? Maybe if I got out climbing more the dream would go away, but for the last year I haven’t been able to climb because of injured shoulders (plural). The injuries were my own fault; I’ve had niggles for a few years but did nothing about them and I certainly didn’t make an effort to get advice from an expert.

The end result was surgery to both shoulders and there were times during my long recovery that I found it hard to imagine ever being able to reach high and pull down again.

However all is not lost, thanks to 21st century surgical techniques, plenty of sometimes exquisitely painful physio and 12 months of healing, I’m now pulling down almost like I used to. Though it isn’t saying much, there is even a chance I may be able to climb harder than before.

In delving into why the bicep tendons in both shoulders became so badly damaged (including being completely torn off in my left), I found one of the contributing causes to be a nasty habit of not using all the muscles that provide power and stability to the shoulder, akin to having four-wheel drive but using only two wheels. This not only made me weaker – because unused muscles will atrophy – but, crucially, led to my shoulder joints becoming unbalanced and exposed to damage caused by instability.

Looking back I must have long been overusing the muscle groups above (trapezius) and in front (pectorals) of the shoulder and the warning signs were all there, had I cared to look. For instance, whenever I came to negotiate a hard pull or lock-off my elbow would tend to swing out, plus I always found it hard to lock-off when mates of equally scrawny build could do it with no training.

Then I started suffering from tendonitis in the elbows, a product of abnormal use exacerbated by shoulder instability putting pressure on my brachial nerve – making my forearms tense, with the consequence that the elbow tendons became overly stressed.

I cured the elbows with rest but when I resumed climbing my right shoulder started to give me trouble, first as a ‘pinching’ pain whenever I lifted my arm up through the horizontal. Later a more persistent pain in my upper arm crept in after a day spent out on the rock – towards the end it hurt at night, especially when I rolled on to the sore shoulder.

Then bigger events caused me to become very stressed and my shoulders and neck stiffened up. To ease the stress I went climbing on the weekends – and so my condition accelerated into a perfect storm of shoulder meltdown. It is all so obvious in retrospect.

The Physio Says: Recurrent shoulder pain is frighteningly common in climbers. Even the best climbing technique subjects the shoulder joint to high forces in its least stable position – with the arm overhead. The design of the shoulder joint allows an incredible range of motion, but with the price of compromising stability. Unlike the knee or the elbow, this large range of motion means the shoulder cannot be held tightly with ligaments, instead it must be stabilised by the group of muscles called the rotator cuff. This group of four small muscles holds the shoulder joint together as your large, powerful muscle groups (like your deltoid, pectorals and latissimus dorsi) generate the force required to move up. To add to the complexity of the situation, the shoulder blade must also have good stability to maintain the specific movement pattern with the arm to allow overhead reach. The only bony structure that attaches the shoulder to the trunk is the collarbone, so again, there’s another set of muscles that needs to be working optimally for good shoulder function. No wonder it doesn’t take much for things to go wrong.

Unless an injury is a definite trauma related to a fall or a dislocation, it is fairly safe to say that all other shoulder pain is biomechanical, either causing an acute pain such as impingement or, over time, development of tendonopathy and degenerative change. The shoulder joint, rather than being a snug fitting ‘ball and socket’ is more like a golf ball on a golf tee – the socket is very small and shallow by comparison with the head of your upper arm bone. When the joint is moving, the situation becomes more like a seal balancing a ball on its nose – anything that pulls too hard in one direction will upset the delicate balance – this is where problems begin. And those problems can hang around at a low level for years, until one day, one awkward move, or one move too many, and you have a significant shoulder injury. By ignoring those niggly pains and, worse still, continuing to climb with pain, your clever goal-oriented brain will compensate and find a new movement pattern using different muscles that may avoid the pain in the short term but set you up for ongoing long-term problems. The importance of good posture and mobility in your upper back cannot be overstated either. Unfortunately most of us spend far too much time sitting at a desk, hunched over a computer and without correction we will stiffen into that rounded position – and our shoulders suffer for it.

The wounded warrior: Of course climbing subjects the arms, from the shoulders down to the fingertips, to all kinds of stresses that may in the end cause inflammation, tissue damage, pain and the wasteland of climbing downtime. The trick is to know when to slow down and begin steering yourself away from the path that leads to injury. It’s like crevasses – much, much easier to avoid falling into one than trying to claw your way out (even better, learn to anticipate where they are likely to occur, be smart and patiently probe your way across).

So, if you start to suffer a bit of pain in the shoulder, especially when you go for that overhead reach, make yourself an appointment with a physiotherapist. Caveat emptor though: like in any profession, not all physios are good at what they do – I struck it lucky on my fourth try. How did I know I’d found the right one? Unlike the others, this practice went back to basics and sought out the cause of my ill while the others just subjected me to a superficial examination, did some massage or acupuncture and seemed more interested in seeing me regularly than seeking out the root and fixing it.

The Physio Says: The one thing that annoys a physiotherapist most is hearing the familiar and frustrating story of nagging pain that has been ‘happening for years and years, but I kept on going and now it’s so sore all the time that I can’t move it, can’t sleep on it and I’m living on painkillers’. If you’d done something to address those niggles, got a proper assessment and a program of stretching and strengthening exercises to address your specific problems, you might never get to this end point of your shoulder in real trouble.

Sometimes the ‘Big S’ of surgery can’t be avoided – a high-functioning shoulder for climbing requires the anatomy to be intact – and even after focussed rehab and ‘conservative management’, the gains are sometimes not enough to have you back climbing. To give yourself the best chance, in seeking an orthopaedic opinion you need a surgeon who specialises in shoulders and who understands your future goal to return to climbing, and is thus able to give you a good prognosis of your potential to do so.

Really the surgery is the easy part and in order to preserve your range of motion you need to move the joint passively soon after you get home. Remember, surgery exposes your shoulder to massive trauma, so rehab hurts. After six weeks you will be able to move the shoulder actively, and progress through range of motion and strength exercises, and finally on to sport-specific training using weights, kettlebells and bodyweight exercises. Rehab can take up to six months and is a process of reassessment in conjunction with your surgeon as you work through a long list of exercises designed to give your shoulder strength in the many directions it requires. One important consideration is that the shoulder does not work in isolation; it is involved in complex whole-body movement patterns when climbing, and this is where lower body strengthening and core stability training become important also.

Follow the simple mantra if you need the knife, you need the physio. The key to recovery is starting early – shoulder surgery without early rehab is a recipe for disaster.