Well, now I've got something to distract me from my knee problems -- shoulder problems!

I don't think running had anything to do with this new physical challenge and fortunately, torn rotator cuffs haven't affected my running, walking, and riding. They have significantly affected my sleeping, lifting, and doing any strenuous yard work or heavy lifting the past six or eight months, however.

The rotator cuff is comprised of four major muscles and the tendons that hold them to the upper arm bone (humerus) and the shoulder blade. You can see diagrams of the shoulder at this (sportsinjuryclinic.net) and other links. The rotator cuff also helps hold the ball of your upper arm bone firmly in your shoulder socket. The combination results in the greatest range of motion of any joint in your body, according to the Mayo Clinic's website.

Rotator cuff injuries can be caused in a number of ways: normal wear and tear after the age of 40; poor posture; falling; lifting or pulling something improperly or that is too heavy; and repetitive overhead movements (such as in sports like tennis, swimming, pitching baseball or occupations like painting or carpentry).

I'm not sure how I hurt my shoulders but I can make an educated guess: all of the above!

I think the main precipitating factor is all that heavy yard work I did last summer: lifting and carrying fire wood around the property, digging and tending the veggie garden, shoveling about a ton of mulch into the bed of the pickup and distributing it in the perennial beds. Etc, in adfinitum.

Gee, ya think?? I'm not 35 any more but I often try to do as much at 60 as I used to twenty-five years ago. <sigh>

Just one of the piles of mulch I spread in the garden last fall;
the departing Asplundh truck left several trees down, too.  (11-12-08)

I also built up to quite a lot of weight and reps (for me) on the Life Fitness machines at the Y last summer and fall. I  may have aggravated my shoulder problems by lifting too much weight and/or inadvertently creating imbalances. I stopped using the chest press, shoulder press, and military press machines last summer because they hurt, even at low weights. I concentrated on bicep curls, tricep press downs, lat pull downs, and the seated row.

Two massage therapists have confirmed that I probably strengthened those muscles too much in comparison to smaller ones I was missing.

Maybe I wouldn't be in this fix if we'd gone on our summer trip last year! I would have avoided some of that yard work and had less opportunity to use weight machines when we were on the road. Of course, that wouldn't have solved the pesky problems of getting older and falling down too much when I run on gnarly trails . . .

Some of the piles of mulch when into this large perennial bed.  (11-17-08)

In hindsight, I didn't notice anything more than general fatigue and soreness during the summer and fall.

After we were in Texas and Arizona for a couple months in November and December I began having problems sleeping on either side, especially the left (my preference). I also began to wince when I made certain motions, like lifting Cody's heavy water bucket up into and out of the bed of the truck with my left arm. Any motions where I raised my left arm straight overhead or bent like a chicken wing (!) became very painful or just impossible. I had to sleep on my back, modify my upper body lifting routine at the fitness centers I was using, and stop lifting the water bucket with that arm.

WIRED

I dinked around with alternative remedies and therapies longer than I should have -- electrical stimulation (below), massage, chiropractic, hot and cold packs. I just had no clue they'd be virtually useless for my particular problem.

While we were in the Huntsville, TX area for the month of February I saw a massage therapist three times and my own massage therapist in Roanoke a couple of times in March and April. Even though they both did lots of deep tissue work around the shoulder blades and upper arms, they still hurt. Both women told me they thought I'd strengthened my biceps, triceps, and lats too much in comparison with some of the smaller muscles in my upper arms and shoulders. Both suggested a couple exercises for me to strengthen the weak areas but they were ineffective.

Three of the four leads to the TENS unit; the fourth is on the front of my arm.

I also saw my chiropractor when we got home. He thought the problem might be " frozen" shoulder blades. Manipulation and ultrasound in his office brought some temporary relief. He also suggested I alternate hot and cold packs and increase the use of my TENS unit (above). I didn't notice any appreciable improvement after doing those things, either. Electrical stimulation worked very well on my sore hamstrings last fall, but it didn't alleviate the pain or weakness in my shoulder.

I would soon find out why.

TIME TO FIND THE RIGHT ANSWERS

I finally got smart and contacted the orthopedic practice we use in Roanoke. It takes several weeks to see an orthopedist there when we have a new problem but we've learned how to get our foot in the door within a few days: ask for a PA versed in the body part with the current problem.

I was able to see a competent young lady named Andrea within two days (March 27). She works with Dr. Larry Miller, one of the two orthopedic surgeons in the practice who specialize in sports medicine and knee/shoulder problems.

Andrea promptly diagnosed rotator cuff injuries in both shoulders. That surprised me because the pain was different than what I'd felt several years ago when I was diagnosed with a minor rotator cuff problem in my right arm, most likely caused by using the lat pull down machine incorrectly (bar in back instead of in front).

That time I was referred for one session of physical therapy and a home program that resolved the problem rather quickly. I started doing the lat machine differently but I don't remember anyone telling me at that time how important it was to continue doing "maintenance" strength and stretching exercises as I got older.

The end result is worth all the hard work, just as it is in ultra running.

This time the problem is in my other arm and it was very sore on the outside, halfway between the shoulder and elbow -- not the shoulder itself. How could that be a rotator cuff problem?? It wasn't very close to that joint.

Well, duh, I was about to learn a LOT about rotator cuff problems in the next few days as I researched further beyond the information Andrea gave me.

Referred pain lower down in the arm is one of the classic symptoms of rotator cuff injuries that are caused by repetitive stress, the most likely cause of my pain. I'm not aware of any one traumatic incident that caused the problem. If that was the case, it would more likely be my right arm that hurt because that's the one I almost always fall on when I trip while running. It's a wonder I've never broken it.

My symptoms, X-rays, and lack of strength in my left arm when Andrea did resistance moves indicated one or more tears in my left shoulder. She felt it was beyond cortisone treatment and recommended an MRI as soon as possible to determine if the tears were partial or complete.

My right rotator cuff is probably not torn, at least not as badly as the left one. Andrea didn't recommend an MRI or cortisone injection on it. She did recommend that I begin physical therapy on both shoulders as soon as I could get an appointment, even before finding out the results of the MRI.

ZONING OUT IN AN UNLIKELY PLACE

I could have gotten an MRI on April 3, just one week later (try THAT with "universal healthcare" or "socialized medicine!"), but we had plans to be at Umstead that day. The next time I could get in was April 7. I went to the same facility in Roanoke that I used for an MRI on one of my knees in 2007.

This time a physician injected dye into my shoulder, standard procedure for a rotator cuff injury. It was very cool watching the screen overhead as the dye worked its way into the joint! Wish I had a picture of that.

I was escorted to another large room for the MRI. I was lying comfortably on my back for about thirty minutes while the pictures were taken. I almost went to sleep despite the loud '70s rock music in my ears, which was designed to drown out the even louder jack hammer staccato of the MRI machine. It didn't, and I was startled back to reality several times when the rat-a-tat resumed. I was so focused on the music, however, that I was surprised when the technician came in to turn off the machine. The time went by quickly.

The MRI center sent my results to my orthopedist, chiropractor, and physical therapist, who I saw next (April 10). Wendy, the owner of the PT practice I chose, gave me a copy of the report and interpreted the results several days before I was scheduled to see the orthopedist.

One of the eleven MRI films of my shoulder

The simple explanation is that I have three small tears in my left rotator cuff (shoulder joint). The good news is that I probably don't have arthritis there yet. Tears in this area are common after age 40 as the rotator cuff loses elasticity. Treatment is similar whether the tears are partial (as mine are) or complete. They do not heal well over time on their own (no joke!).

The goal of treatment is to relieve the symptoms (pain and weakness), not necessarily to heal the tears. In my case, the best treatment is to strengthen the surrounding muscles so they can support the joint properly and to stretch them so my range of motion is increased back to normal.

And thus began a quickie course of physical therapy with the intention of strengthening my shoulders as much as possible before we head out of Dodge again.

Dr. Miller reiterated much of what Wendy told me (and what I'd found on the internet) when I saw him on April 15. Even though I had a list of questions about therapy and surgery I asked Jim to accompany me so he'd better understand what was going on and pick up on things I might miss.

We still don't fully understand the orthopedist's explanation of de-lamination of one of the muscles or tendons but we clearly understand that surgery is not a viable option. As the other sports med and shoulder/knee specialist in the practice, Dr. Brent Johnson (the doctor I saw for my knee problem), likes to say, trying to repair a torn rotator cuff is like trying to stitch together wet toilet tissue!

That's pretty graphic and not very optimistic.

Using the biceps resistance machine at the Y last summer (6-25-08)

We talked about what treatments are best for me (proper weight work and at least six weeks of physical therapy for more strength, balance, and flexibility), what treatments won't do me any good (cortisone shots or a sling), and what therapies are neutral -- neither harmful nor very helpful (massage, chiropractic adjustments, ultrasound, electrical stimulation/TENS unit, or heat and cold). Ibuprofen is fine for the pain, since I'm taking it for arthritis anyway.

Surgery is the last resort, and one I'm not anxious to try. I've heard horror stories from my sister and friends who've had shoulder surgery; it is described as one of the most painful surgeries from which to recover. So I've been working my butt (no, shoulders) off in PT at one of Wendy's offices a couple times a week and at home every day. I need more muscle strength and balance, better external rotation of my arms, and better posture.

Mom was right: stand up straight and keep your shoulders back!

My medical providers also confirmed one more probable cause for my rotator cuff problems: sleeping mostly on my left side for the last 50 or 60 years. By necessity I've learned over the last six months to sleep mostly on my back.

SUCCESSFUL PT

I love my PT sessions. Problem is, since we're leaving town soon I have less than four weeks to get in six weeks' worth of therapy.

Each time I go in for treatment one of the assistant therapists puts a heated pack on my shoulder to warm it up before Wendy comes in to evaluate my progress regarding strength, resistance, and range of motion. After we talk she formulates a revised, more advanced plan and gives it to one of her assistant PTs, who shows me how to do the new exercises and puts me through the paces of some of the older ones. Then I sit with a cold pack on my shoulder for a few minutes while the new diagrams and instructions (including weights and reps) are printed out for me to take home. Each session lasts an hour or more.

After three weeks I'm up to twenty-one strength and stretching exercises a day! That's a bunch. I can remember most but not all of them; I have to refer to the diagrams so I don't miss any. Some use both shoulders at the same time, like the tough alternating one-arm version of a push-up that I do on the floor 40 times (I switch arms every few seconds so only one at a time is supporting my weight):

 

(Jim took those pictures in our camper on May 29, the day I uploaded this entry.)

Most of the exercises must be done separately for each shoulder. I'm concentrating on the left (worse) side but doing the same ones most days on the right side, too.

This has become very time-consuming, about 90 minutes for the whole routine. I usually break it up into two or three sessions because my arms get too sore to do the moves correctly with the weights, Thera-Bands, and/or body resistance against the wall or floor. Breaking up the sessions also gives me time to do other things around the house.

When I began therapy I assured Wendy that I was highly motivated and would work very hard because 1) I knew I had a lot to do in a very short time and 2) I was real tired of being in pain and having limitations with that arm. I was wearing one of my Leadville 100 shirts. I'm pretty sure that sent a signal that she could trust my promise! Although she started me off slowly that first session, she rapidly upped the ante each successive visit.

My diligence and compliance have paid off. Wendy is very pleased with my progress. I have significantly more strength and range of motion in both shoulders/arms in just three weeks.

Wendy's not real surprised at my tenacity. She's a distance runner herself and knows the general mentality of athletes who participate in extreme sports like ultra running. The same personality traits that make us endurance athletes make us strive purposefully toward other personal goals. Wendy and I have had a good professional relationship because we are like-minded and working toward the same goal during treatment.

A 4x16-foot garden may be small, but building it from scratch last summer
probably contributed to my rotator cuff problems. (5-1-08)

I have time for just one more PT session before we leave town. Wendy will give a final assessment of my progress, forward that information to Dr. Miller, and give me two plans: a rigorous one for the next three weeks and a maintenance plan for the remainder of the summer.

If I feel the need for more therapy before I return to Roanoke in the fall, I can get a new prescription from Dr. Miller and try to locate a physical therapist wherever we are camping at the time. That's not real practical, so I'll do my best to adhere to the program on my own.

Neither shoulder is 100% yet, but I'm already able to sleep much more comfortably and don't have near the pain in my left arm when I make the "wrong moves" as I did before beginning therapy.

That garden a month later; by July it was a jungle but producing heavily.  (5-31-08)

It's fun to be a successful patient! Progress is good. But from everything I have read I will probably have to continue some of these exercises for the rest of my life in order to prevent recurrences, even if I avoid doing some of the strenuous things I'm wont to do (yard work, moving furniture and heavy boxes, etc.).

These are the lessons I've learned from this experience:

• don't do so much heavy lifting, especially overhead
• don't do so much other strenuous work around the house and yard (a big problem when we sell the house and have to move everything out)
• don't create muscle imbalances
• don't slouch
• don't sleep all night on either side, especially the left
• don't fall down so much when I'm running trails
• don't expect to do as much as I used to be able to do
• don't get old!  (just kidding)

DON'T WANNA GO THERE

Two of the times I was in the large room where the PT's were working with several other patients I got to watch a well-dressed, sophisticated-looking woman in her 60s or 70s who had double knee replacements several weeks ago at Duke University. I forgot to ask her why she went to Duke but I did get to ask a few other questions after our sessions.

One of the obvious ones was, "Why did you get them both done at once?" She gave me the answer I expected: "Because I never would have gone back for the second one if I'd done just one the first time."

Maybe shoulder surgery isn't the most painful from which to recover! I know people who've had one knee replaced -- and then, miraculously, the other bad knee doesn't feel so bad any more!

It's the same rationale Jim used in 2003 when he had surgery on both feet and calves at the same time for bunions, Morton's neuromas, and gastroc releases (a total of SIX surgery sites!): he probably wouldn't have elected to go through "da agony of da feet" a second time.

Jim's feet the day the bandages came off.  (11-11-03)

Hope you aren't eating lunch while you read this entry!

If I do have to have my knees replaced (I'm hoping for some scientific advancements before I'm forced to do it) my current thoughts are that I'd do both at once, for the same reason this woman did. She was in obvious pain each day I saw her at therapy but she was working hard to gradually build back her strength, stability, and flexibility. I saw quiet determination through her gritted teeth and the tears she was trying so hard to hold back.

I could visualize myself in her position. And this should come as no surprise -- my knees feel better now!!

I learned something else that's important from this woman. She put off getting treatment until surgery was her only option; she had lost too much cartilage in her knees to even try injections of synthetic materials. Now I know I need to get in to see Dr. Miller or Dr. Johnson before it's too late for injections, which might delay the need for surgery.

Next entry: what a drag it is getting old (hum along with the Rolling Stones . . .)

Happy trails,

Sue
"Runtrails & Company" - Sue Norwood, Jim O'Neil, and Cody the Ultra Lab

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© 2009 Sue Norwood and Jim O'Neil