Case Study: Persistent Shoulder Pain

Whenever presenting a case study, it is important to understand that it is not meant to be a step-by-step solution for your own individual circumstances.  Everyone is different and what helps some may hurt others.  It is my hope that you take the principles explained in this case study and apply them to yourself under the guidance of a qualified healthcare provider.

This case study involves a 42-year-old recreational weight lifter and 3DMJ follower with persistent shoulder pain.  Let’s call him Sam.  Sam described the pain as severe soreness after pressing movements, which typically lasted over 24 hours.  There was no pain during training, which made it difficult for Sam to gauge what exactly was provoking his symptoms.  The pain persisted for over a year and Sam was becoming quite frustrated.  He is a business owner and father of two young girls and training is foundational to his overall mental and physical well-being.  Sam was concerned that his shoulder would eventually get worse and prevent him from training and carrying out daily activities.  

Before he reached out to me, Sam saw an orthopedist who referred him to a local physical therapist.  The physical therapist focused on soft tissue release of the pecs and lats as well as fixing his forward shoulder posture with corrective exercises.  Sam was also advised to avoid weight lifting for the time being.

After a few weeks of only mild symptom relief, Sam reached out to me for some help.  At this point, he had gone against the recommendation of his physical therapist and had started training again.  Since his previous healthcare providers left him on his own in the training department, he simply did what made sense to him.  In an attempt to find an exercise that didn’t provoke his pain, Sam had been changing his pressing exercises each week: bench press, Swiss bar press, dumbbell press, machine press, barbell overhead press, dumbbell overhead press, etc.  Some weeks he would even skip pressing all together.  He also added in isolated rotator cuff strengthening exercises 6x/week and made sure to pin his shoulder blades down and back throughout the day and during all exercises to help with his forward shoulder posture.  He was pressing 2x/week for 4 sets at RPE 8.

Since Sam was able to train pain free and his symptoms were only present after training, it made sense to focus on overall workload rather than things like exercise technique or range of motion.  Something about his workload management was causing his load to exceed his capacity (see my blog for more on workload management).  In cases like this, I tend to focus on volume, intensity, frequency, exercise selection, sleep, stress, cool down techniques, and some simple at home relaxation and pain-relieving exercises.  

We started by choosing a main horizontal pressing movement and sticking with it for a few weeks to give the body a chance to adapt.  By changing exercises as much as Sam was, he may have been introducing novelty each week and not allowing the repeated bout effect to take place.  The repeated bout effect is basically the idea that the more we do something, the more efficient we get at it.  We selected the barbell bench press as the main horizontal pressing movement and the landmine press for his main overhead pressing movement because it allows for autoregulation of overhead range of motion and bar path.  Lastly, instead of 4 sets at RPE 8 on all exercises, we decided to change it to 3 total sets, with an RPE 6 on sets 1&2 and an RPE 8 on set 3.  This allowed us to decrease volume and proximity to failure while maintaining a training effect and keeping him engaged.

Aside from programming modifications, I also suggested removing the isolation rotator cuff exercises to reduce weekly rotator cuff volume.  Sam initially took comfort in the thought that he was “doing something” to help his condition and figured the more he could do, the better.  I explained to Sam that “weakness” of the rotator cuff was likely not a main contributor to his symptoms and that the rotator cuff was actually getting plenty of volume with his normal training routine.  By adding as much extra rotator cuff work as he was, Sam could have simply been blowing past his body’s capacity to recover.  

I also educated Sam on proper “scapular mechanics.”  I explained that the shoulder blades must move forward and elevate around the rib cage at times for proper shoulder function.  For example, I coached Sam on allowing the shoulder blades to elevate on lateral raises and protract on landmine presses. 

So, did it work?  With injury management, where we start is not as important as the ability to analyze feedback and make changes as needed.  Starting the process is like adjusting the water when getting into the shower.  Usually, we put the dial somewhere that makes sense between hot and cold.  We then feel it with our hand and adjust.  Then we put our foot in and adjust.  We then step in and, you guessed it, adjust.  The point here is that we pick a logical starting point and maintain an open adjustable system.  This becomes a bit more challenging when considering the complexity of the human system and psychosocial factors, but that’s where skill meets art!

After one week, Sam’s pain after training lasted only an hour, rather than 24 hours, a great start!  He also reported his shoulders felt much less restricted and tight since allowing his shoulder blades to move as they pleased throughout the day and during training.  After a great first week, we decided to make one small progression.  We decided to do sets 2&3 at RPE 8 rather than just set 3.  This was just enough of a progression to be conservative while allowing for Sam to feel like we were moving in the right direction.  

And that brings us to current day.  How will Sam’s progress go from here?  Who knows?!?!  I am confident that if we continue to lead with principles and maintain an open adjustable system, shoulder pain will be a thing of the past for Sam!  Stay tuned for an update!