I deleted this post over five years ago, back when I was testing for SJPD.  I didn't want to be judged for it and have it keep me from being hired, so I removed it.  I have been meaning to repost this for a long time and am finally doing so now.


Bleed Need

In your reading or studying or life thus far, have you come upon any significance, whether symbolic or otherwise, of the forearms?  This has plagued me for quite some time.

For whatever reason, the forearms have had significant "power" and meaning to me throughout my life.  There have been a few in my chosen household over the years that felt this strange significance as much as I do, though none of us can effectively describe it to our satisfaction.

Considering I grew up in a Judeo-Christian society, it is possible that the crucification image dropped something into my brain.  There are Chi (not the stuff you drink, lol) lines that run along pulse points from elbows to wrists that are supposed to be some of the most potent in existence (assuming one believes in Chi).  Native American tribes sealed bargains of great importance by blood-bonds (joining cut hands or wrists to mingle blood).  The "Warrior's clasp" of Roman and Celtic tradition is a clasp made at the forearm rather than simply shaking hands.  The "marriage clasp" of Eastern European tradition is the same as the warrior's clasp.

The forearms have always had some deep significance to me.  It is where I used to cut myself when I was younger.  It is where I still phantasize about cutting myself every time the urge resurfaces.  It is where I had envisioned slitting myself upon my departure from this earth.  And it is where I have greatly pondered getting tattoos that are of great significance to me as a person.

I do not voice this for sympathy.  Only insight.  If I am judged for talking openly about it, then so be it.  I will not judge those who judge me for discussing this.  I understand.  Cutting carries with it a preternatural stigma.  If you cut, you are broken.  Most find unfiltered veracity in communication to be disconcerting, to say the least.  I am not and was not crazy.  I was just a scared, wounded little kid with a lot of pain and *NO* one to talk to.  I was alone with all my demons to keep me company.  (I don't wish to "slay my demons", as the saying goes.  I'd rather sit and talk with them over lunch.  They usually always have something interesting to say.)

When a friend of mine (Matt R) was in junior high, he carved an M into the belly of his left forearm.  He never really knew why he did it, but he remembered telling people that it was for "Me", not necessarily his name but just for “me".  One of his best friends who has been through a lot, including the suicide of his father, also carved an M into his forearm.  When Matt asked him what it was for, since he has no M's in his name, he said that it was for "Myself, my mom, my girlfriend, and for you”, and also that he didn't really know why he did it.  When my friend told him that he carved an M into his arm in junior high for "Myself" they both got a little freaked out since at the time that my friend did it, they hadn't even met, and when his friend did it, he had no way of knowing that my friend had done the same thing for similar reasons (if there was any).

Along with the symbolic significance of the forearms, there was a deep need to see my own blood when I was a kid.  (I now have permanent scars to remind me of it.)  I think it must have been symbolic of release.  Or perhaps self punishment.  Or yet it could be something else.  I think it is symbolic of release and, being painful, also of making atonement (self-punishment), but there is more to it.

Perhaps it just be some psychosis of sorts, though I argue otherwise.  Self-mutilation is an amazingly common response to stress.  Animals do it.  A stressed out bird will "preen" itself bald - pulling out strongly attached feathers until it literally bleeds to death from several tiny wounds.  Snakes will shred their flesh on rocks even when not in shedding-season.  Some animals will scratch themselves deeply and repeatedly when under stress, etc.

Pain is a shocking experience even in relatively small doses.  Perhaps subconsciously we self-inflict pain to, a), stimulate the production of endorphins, and, b), stimulate the production of adrenaline.  We're giving our body the added push it needs to produce chemicals we don’t have in adequate supply to respond to the stress we’re under.

Also, there may be an instinct to bleed one's self in order to *lower* some chemical in the blood -- after all, less blood also means less [insert chemical of your choice here] running through the system.  There may be hope that the pain itself will "reset" the system.  However from a spiritual viewpoint, there is power in blood.  *Every* religion attaches some significance to blood and to it's shedding or sacrifice.  "This is my blood, shed for your sins" etc.  In most cultures system of magic, blood is used to cement rituals as a last-ditch drastic effort.  Blood magic is usually considered to be extremely potent and also is usually forbidden.  

Although, I think the bloodshed may in fact be an external embodiment of what we are feeling within, a manifestation of our own pain into a tangible for the external senses to experience as well as the inner.  I think sometimes it is just a desperate need to get something intangible yet real out of my system by any means necessary.--As though I’m trying to fix something…though not knowing what I am trying to fix.  Being practical, I cleaned the wounds in warm water and alcohol (I never went anywhere for medical care) and both hurt like hell.  I just wanted to bleed.  I needed to.  It was strangely therapeutic for me, and still is in times of extreme stress and duress.

As for my departure from this earth, I had pictured slitting up the belly of the forearm from wrist to elbow.  (Just think Terminator-2.)  I could picture myself sinking into the warm water of the tub and as the blood flowed from my body, I would be consumed with an overwhelming sense of "Aaahhhh".  An overwhelming sense of finally having *peace*.

Actually this is extremely painful.  The water makes your wrists and arms throb horribly and that usually starts your other muscles cramping as your nervous system pumps adrenaline into a still body.  It generally sucks.

At the end of the first pint (if someone doesn't find you before you bleed that much), you're quite dizzy, have probably vomited at least once (usually pure bile as most people do not slash on a full stomach) and you get a migraine from the change in blood pressure.

By the end of the second pint, your ears start ringing horribly and you get a bit feverish.  You now really want to be away from the water, just to make the nausea stop, but the nausea is an after-affect of losing the blood, so escaping the tub (which you can't really do because your feet are starting to fall asleep) is not likely.  By now one usually decides this was a really poor choice and perhaps you should have slit your jugular so you could have bled faster.

By the third pint, you're both fevered and shivering, and your lips are blue.  Your entire body aches because every capillary you have is constricting in a desperate attempt to conserve your much-needed fluids.  At this point your eyesight starts wavering.  Somewhere between dry heaves you might manage a strangled cry loud enough to bring someone from the next room over.

Overall, wrist slitting is highly overrated.  Perhaps Nicotine poison is a better choice.  Take the tobacco from three cigarettes.  Put them in a solution of 90% isopropyl alcohol.  Boil.  Repeat.  Boil the mixture until it dries, then grind it up into a powder.  Add powder to drink of choice.  You have fifteen minutes.  There's no fast-enough acting antidote.  If you're more given to homicide than self-destruction, strain and press the tobacco and boil away the left over liquid -- the resulting powder is colorless, odorless, and tasteless in any liquid and dissolves completely without stirring.  This is not a joke; I do not suggest one make this material for fun.  Possession of it in this form is usually an automatic felony in most states.

I do not understand the significance of the forearms, but I feel it very deeply.

Nor do I fully understand the urge to cut, or more precisely, the urge to bleed.  (It is not so much the cutting as it is the bleeding that brings the greatest calm, at least for me.)  I still do not fully understand it, but I still feel it deeply at times of greatest stress an duress, and when I feel I am the cause of losing something I cherish.

No one talks about cutting.  If you cut, you are broken. The shame, embarrassment, fear of being judged, fear of being committed, fear of being accused of seeking attention, and more, those feelings, combined with a sometimes crushing depression or overwhelming feeling of being alone, and it never is discussed.  So no one talks about it.  I’m not seeking attention or sympathy by talking about it.  It is simply a part of me that I am trying to understand, and maybe it is not as preternatural as the stigma it carries with it.

...Why I don't "Got Milk".

Recently, Harvard University hosted an extensive debate on the subject of Raw Milk vs Pasteurized Milk. It’s been a topic of hot contention for some time now.

In the realm of CrossFit, Paleo and The Zone, CrossFit athletes are sometimes confused about whether or not to even consume dairy, and if so, when.

Dairy is considered “Zone friendly” with foods such as cottage cheese serving as an excellent source of quality protein and amino acid sequences necessary for the repair and building of lean muscle mass, and milk being a perfectly Zone balanced food.

Over the years, many Body Builders, Power Lifters and Strength Athletes alike have tried the “gallon of whole milk a day” program to aid in putting on mass, (myself included). While this protocol can certainly put on “mass”, much of it will be fat.

A much better method is that recommended by John Wellbourn of CrossFit Football for their Power Athletes and Football Players trying to add quality muscle mass and size while staying healthy. The CrossFit Football approach is to basically eat all “Paleo” foods, yet allows for the consumption of whole milk immediately after a wod, stating; “One gallon of whole Milk contains 2400 calories. This is an excellent source of proteins, carbohydrates and fat. Dense calorie sources are a must, like whole milk and meats.–There is growth potential beyond calories by consuming whole milk. Increased IGF, hGH, insulin, testosterone come from drinking whole milk. These are all potent growth promoters.”

…I was asked by a client of mine a while ago who had just read a popular Paleo book that I let her borrow, “Why is dairy bad?–He says repeatedly how ‘dairy is bad’, but doesn’t go into the science of why.”

…Turns out, a lot of people have this same question.

There’s a lot of back-&-forth as to how bad dairy actually is for human consumption, even within the “paleo” and “paleo-ish” community. There is also a lot of “grey area” in regards to some of the science. The rhetoric around pro vs anti dairy get’s pretty silly sometimes. The anti-dairy proponents say “humans are the only animals on the planet that drink milk after infancy and that drink milk of another animal.” Those who wave the pro-dairy banner come back with “if you put a bowl of cows milk in front of a cat, it will drink it.” (Much like “If you gave a caveman a hot pizza, he would eat it!” Haha) It get’s kind of ridiculous. Yet when it comes to the actual science behind it all, you can get pretty in depth in trying to sort through it.

Regardless, some forms of dairy seem much more problematic to the human system than others.

One of the problems with some forms of dairy is that it causes a higher insulin response than glucogon response. Part of what we’re looking for when consuming protein is not simply the amino acid sequences for which to rebuild and repair muscle, but an overall glucogon response and thus a balancing of the insulin/glucogon hormonal axis. Dr Barry Sears, author of “The Zone”, covers the importance of balancing the glucogon/insulin hormonal axis extensively in his books, yet he approves of dairy stating that it’s a “perfectly Zone balanced food”.

However, milk causes a substantial insulin spike. The insulin index for whole milk is 148, and for skim milk, 140. According to Matt Lalonde, (Ph.D in Organic Biochemistry from Harvard University), the virtually identical insulin responses from both whole milk and skim milk indicate that the specific protein/carbohydrate makeup of milk is responsible for the observed insulin secretion, not the fat. Thus choosing a “low-fat” milk is in no way a healthier choice in this regard, (and is in reality an UNhealthier choice). When you look at cheese and some non-sweetened yogurts, you get much lower insulin indices. Cheese yields an index of 45, which is lower than say the 51 of white fish. So, according to Matt Lalonde, some fermented dairy where the lactose has been eliminated, preferably from a grass-fed source, can be “OK” for people who don’t have autoimmune diseases, though it shouldn’t constitute a majority of daily calories. People with autoimmune diseases should avoid it altogether. Period.

There are other problems with dairy as well. Casein is the primary protein in dairy and especially in milk. It shares several structural similarities to gluten. Just like gluten, casein proteins are rich in the amino acid proline and can shred the intestinal lining contributing to leaky gut syndrome and severe auto-immune issues. (If you are participating in our current Paleo Challenge 2012 and you heard Cliff’s kick-off presentation, then you are likely all aware of the many problems with gluten, including leaky gut syndrome.)

Mark Sisson of “Mark’s Daily Apple” (a great paleo blog I link to from my blog) and author of “The Primal Blueprint” acknowledges that paleo opponents of dairy say casein wreaks similar havoc on our guts as that of gluten, and that gluten intolerance goes hand-in-hand with casein intolerance. But he then asks if casein is a primary cause of leaky gut, or if it just slips in only after gluten has opened the floodgates, stating, “Once a floodgate is opened, any protein can enter and cause issues.” He then adds, “and after all, casein is the primary protein in human breast milk…”

While yes it is true that casein protein is the primary protein in human breast milk, Mark Sisson fails to acknowledge that the proportion of caseins, as well as their structure, in the milk of animals differs from one species to another (i.e. the casein in cow’s milk is NOT the same as the casein in breast milk).

A key area we want to significantly control/mitigate with diet is systemic inflammation within the body. Dairy seems to cause a systemic inflammatory response in humans. Some more than others. While there are multiple factors in this process, it is partly due to the casein protein. Casein has been documented to break down to produce the peptide casomorphine, (beta-casomorphine-7 or BCM7), an opioid that appears to act primarily as a histamine releaser. This peptide causes systemic inflammation in the body and plays a role in joint pain, digestive issues and leaky gut syndrome.

However, milk proteins are made up of different beta-caseins which vary between cow breeds. The most common beta-caseins are A1 and A2. A1 cows (Holsteins and Friesians) produce A1 beta-caseins, which release the problematic BCM7 upon digestion. These breeds of cows produce more milk and so are used by most conventional factory dairy farmers for mass distribution of milk to the public, as well as products made from milk such as cheese and yogurt.

Certain breeds of cows, such as Jerseys and Gournseys, (as well as sheep and goats), produce A2 milk that is free of the problematic A1 beta-casein produced by Holsteins and Friesians. (The often studied Masai people of Africa have cattle [Zebu cows] that produce A2 milk, free of BCM7.)

…There’s various other issues with dairy as well, such as causing increased insulin resistance, something we really want to mitigate. Several studies have also shown that dairy, especially milk, causes leptin resistance at the blood-brain barrier. Leptin is one of the most important adipose derived protein hormones and plays a key role in regulating energy intake and energy expenditure, including appetite and metabolism. Obesity is strongly associated with leptin resistance.

Several studies show increased risk of cancer via abnormally high levels of IGF-1 in cows treated with biosynthetic bovine growth hormones rBGH, as well as inducing post-meal hyperinsulinaemia, shifting the HGH/IGF-1 axis to permanently increased IGF-1 serum levels. IGF-1 can bind and activate the insulin receptor. In humans, insulin and IGF-1 signal the body to grow…both bigger and older. This is why dairy contains IGF-1 and is a potent stimulator of insulin secretion. IGF-1 is non-selective, thus it will make cancer grow as fast as any other cells in the body. The research also suggests the possibility that milk consumption during pregnancy could adversely affect the early fetal programming of the IGF-1 axis which could ultimately influence risks later in life.

Yes, …when training and eating right, we are indeed “striving to optimize our natural levels of testosterone, HGH, and IGF-1” so as to provide our bodies with higher levels of those hormones, yet when done through a combination of sound nutrition and efficacious training, there is a balance between the many hormonal axis’s. We don’t end up with so much IGF-1 that it shifts the HGH/IGF-1 axis to permanently increased IGF-1 serum levels like we see in someone who drinks a lot of milk. Doing Back-Squats wont give you cancer.

…But, let me digress….

I highly recommend you all check out Robb Wolf’s Paleo Podcast #68. Matt Lalonde is a guest in that episode and he is presented with some outstanding questions for which he answers exceedingly well. (You can listen to it in mp3, or download a transcript.) Not only is Lalonde exceptionally knowledgeable and thorough in the realm of Nutritional Biochemistry and himself 100% Paleo, but he calls out everyone in the realm of nutrition and points out all the flaws of the biased research being touted by all sides. Like Gary Taubes, he is unbiased and doesn’t buy into anyone’s BS. He rips the proponents of paleo with their flawed logic just as much as he does Senator George McGovern and the Governments flawed research behind the USDA food pyramid. Like Taubes, he wants to see legit science.

…Ultimately, when it comes to dairy, it’s your choice. Robb Wolf suggests removing it from your diet completely for 30 days and note how you feel, perform, etc. Then gradually re-introduce it in small quantities to see how it affects you. However, I would still highly recommend avoiding milk at all costs. Matt and Robb both agree on this; avoid milk.–Period. …Yes, Matt Lalonde will sometimes have a small amount of cheese, non-sweetened yogurt, ghee or heavy cream, but he makes sure to source it from not only Grass-Fed Cows, but Grass-Fed A2 cows that are free of the problematic BCM7. This is an arduous task to say the least, even in stores like Whole Foods or New Leaf. If you ultimately do decide to “go dairy”, don’t get low-fat dairy because one of the benefits of full-fat dairy is the quality of fats you’re getting, especially if it’s grass-fed. …Don’t drink milk, even if it’s grass-fed.

Robb Wolf still sees inflammation and allergy type stuff in clients trying to use grass-fed dairy. This is purely observational and in no way “scientific”, yet it’s of interest. …My dear friend, one of CFWSC’s very own, someone I’ve trained for many years, finally decided to try giving up dairy altogether for a month after having been “paleo-plus-dairy” for several months. After just a month, she said she feels SO much better and will likely never go back to dairy. …Another CFWSC athlete completely eliminated dairy from his “paleo-plus-dairy” diet and said that the chronic inflammation in his elbow tendons that inhibited him from doing virtually any pulling motion had completely went away. Despite his previous adherence to an otherwise all paleo diet, with the exception of dairy (whole milk after every workout in an effort to add some mass) he still had this chronic inflammation of the elbow tendons. Just to be sure, he reintroduced a small amount of dairy for about 4-5 days and sure enough, the inflammation in the elbow tendons came back. …Another friend of mine and CFWSC athlete (and Master’s Champion) has been very strict paleo for many months and seeing truly exceptional results. He decided to gradually reintroduce a small amount of dairy (cheese) just to see how it affected him. Initially, he hadn’t noted any real differences. However, after 3-4 weeks he noted that he started to get sick, felt more “inflamed”, especially in the elbow joints, and had overall less energy. He has since eliminated dairy again and is feeling much better.

If you absolutely need to do a bit of dairy but want to avoid BCM7, I’d recommend opting for Goat or Sheep based options such as Goat Fetta or Sheep’s Cottage Cheese. Both are available in most health food stores.

While I may, on occasion, have a little bit of heavy whipping cream in my coffee (NOT 1/2-&-1/2), …I will likely never drink milk again, ...no matter how damned good it tastes.

...To all my friends at San Jose Police Department and the CrossFit SJPD Underground team, (a.k.a.; "CrossFit Nomad's");

...I love you and I miss you and I hope to see you all again soon.

...And thank you; ...you have all added to my life significantly. I'm truly grateful that I had the opportunity to meet you, coach you, and get to know you. Our time together holds a special place in my heart. Thank you for making my life that much better. :)

Wishing you and your families a wonderful Holiday, my friends.

Merry Christmas and Happy Holidays. :)

Jason Highbarger

PS: ...Always remember, ..."Hone that mental focus!" :)

(Note: A shorter version (less technical anatomy stuff & sans references) can be found on the CrossFit West Santa Cruz Blog in four parts; Part I, Part II, Part III, and Part IV.)

Have a "Bad Shoulder?" Read this.

Any serious athlete, regardless of sport or training methodology, will get injured. These injuries can range from occasional minor discomfort to career ending maledictions. Lately, several local athletes, myself included, have struggled with shoulder injuries. Some of the injuries have been recently incurred; whereas others have been more chronic in nature. Now before we get too far along on our "bad shoulder" stories; we should pay respect to what an amazing and complex mechanism the shoulder really is.

The shoulder has the greatest range of motion of any joint in the human body. It can lift, pull, push, punch, throw, climb, brachiate, and do pretty much anything else we need it to. Comprised of 4 joints, 5 bone groups, 2 cartilage types, 11 muscles, and a complex interplay of tendons, ligaments, cartilage, nerves, blood vessels and bursae, the shoulder complex can abduct, adduct, rotate, raise and lower in front and behind the torso and move through 360° in the sagittal plane, allowing for complete global movement and positioning of the hand anywhere in space.

Through the dynamic mobility of the shoulder, we can accomplish truly remarkable feats; ...from Snatching 199 Kilos or achieving perfection on the Rings, ...to perfecting a masterpiece on a cello, (part 2) or painting one on the ceiling of the Sistine Chapel (and here). ...The shoulder itself is a masterpiece.

However, ...the tremendous range of motion and complexity of the shoulder joint also make it inherently unstable and prone to injuries. Knowledge of this innate instability dates as far back as Hippocrates (ca. 460 BC – ca. 370 BC). Shoulder injuries can vary dramatically, but the injury I want to specifically address here is the bicep tendon slip phenomenon, or “Biceps Tendon Subluxation”. When the proximal tendon of the long head of the biceps brachi slips out of the bicipital groove and shifts either forward or backward, (usually forward) significant pain and decreased mobility ensues. But, for most people there is a relatively easy, non surgical, fix that can get you up and training again within a week or two, depending on the causal mechanism behind the subluxation.

ANATOMY:

To better understand this injury, some knowledge of shoulder anatomy and that of the biceps brachii muscle is needed. (For a short and very easy to follow CGI video of the inner workings of the shoulder, click here. It will provide a solid mental image when reading further.)

There are three primary bones within the shoulder girdle; the clavicle (collarbone), scapula (shoulder blade) and humerus (upper arm bone). The roof of the shoulder is formed by a part of the scapula called the acromion.

There are three primary joints within the shoulder complex; the Glenohumeral joint (GHJ), a ball-and-socket type joint where the humerus meets the glenoid on the scapula; the Acromioclavicular joint (ACJ), a gliding joint where the clavicle meets the acromial process; the Sternoclavicular joint (SCJ), formed by the joint space between the sternum (breastbone) and the clavicle and is particularly important in throwing and thrusting movements; and one false joint, the Scapulothoracic joint, where the shoulder blade glides against the thorax (the rib cage).--Though not a “true joint” in the sense that it has no capsule or ligamentous attachments, the scapulothoracic joint is important to the shoulder complex because it requires that the muscles surrounding the shoulder blade work together to help keep the socket lined up during shoulder movements (1,4,62,63,66).

Of particular interest, however, is the Glenohumeral Joint (GHJ). Considered to be the main shoulder joint, it is the most important of the shoulder articulations as it provides the greatest mobility. This joint allows the arm to move in a circular rotation as well as towards and away from the body and hinge out and up away from the body. Though commonly referred to as a “ball-and-socket” type joint, the GHJ is not a true ball-and-socket like the hip. The shoulder is different from the hip in that the hip is a weight bearing joint and the shoulder is a suspension joint. In the GHJ, the head of the humerus is quite large in comparison to the glenoid fossa and is closer to that of a golf-ball sitting on a golf-tee. The "ball" of the joint is the top, almost perfectly rounded, medial anterior head of the humerus, and the "tee" is formed by the small, very shallow dish-shaped glenoid fossa (cavity) on the lateral side of the scapula, into which the ball fits. Both articulating surfaces are covered with articular cartilage that is a hard, shiny cartilage which protects the bone underneath. True to the “golf ball on a tee” analogy, the socket comes in very little contact with the round head of the humerus, resulting in only one third of the head being in contact with the fossa at any one time. While adding to the joints mobility, this poor fit also makes the joint unstable. Thus, it is up to the soft tissues in the joint to maintain stability and mobility.

The soft tissues of the shoulder include the Articular Capsule, Bursa, Glenoid Labrum, Ligaments, and muscles and tendons of the Rotator Cuff.

Having a tough, fibrous outer membrane and lined by a thin, smooth synovial membrane, an articular capsule (joint capsule) is a soft tissue envelope that surrounds a synovial joint. In the shoulder, the articular capsule encompasses the GHJ and attaches to the scapula, humerus, and head of the biceps, though is loose enough to allow a wide range of motion.

Bursae are small pad-like sacs that secrete synovial fluid to help reduce friction and aid movement. In the shoulder, they cover the rotator cuff tendons and protect them from the overlying acromion process.

The glenoid labrum is a unique rim of circumferential fibrocartilage attached to the periphery of the glenoid cavity and plays a critical roll in the shoulder. It largely serves to increase the area and depth of the glenoid fossa, aiding in the joints stability, but also serves as the primary attachment site for the shoulder capsule, glenohumeral ligaments, and often the long head of the biceps tendon.

Ligaments attach bones to bones, and there are several important ligaments within the shoulder complex, including the Transverse Humeral Ligament (THM) and the semicirculare humeri, but I will address ligaments in a moment.

The stability of the glenohumeral joint (GHJ) depends on keeping the humeral head (“ball”) centered in the glenoid fossa (“socket”) of the scapula. The humerus is held in place with ligaments, tendons and muscles, mainly the muscles and tendons of the rotator cuff (1,5,39).

The rotator cuff is a group of four small muscles; supraspinatus (abducts the arm), subscapularis (internally rotates humerus), infraspinatus (externally rotates humerus), teres minor (externally rotates humerus) and their tendons that originate on the scapula and attach to the tuberosities on the humerus (1,5,39,63). These envelope the GHJ and function together as a unit to compress the head of the humerus into the glenoid fossa (keeps ball in socket), helping to add power and stabilize the shoulder while in motion (1,4,5,39,63). The rotator cuff muscles also allow the upper arm to move in all directions.

Another integral component to the power and stability of the shoulder is known as the Ligamentous Pulley System. This system consists of several ligaments and tendons that collectively serve as an important stabilizing complex and support structure within the shoulder. This system includes the coracohumeral ligament, glenohumeral ligaments (superior, medial, inferior, posterior), subscapularis tendon, and supraspinatus tendon (2,7,9,11,12,17,26,45,51,57).

The coracohumeral ligament and superior glenohumeral ligament form a U-shaped anterior suspension sling surrounding the biceps brachii tendon near its exit from the bicipital groove (21,49,51,55,56,64,65). These combine with the superior fibers from the subscapularis tendon and are believed to act as a pulley, which is critical in keeping the biceps tendon from subluxating (slipping) or dislocating (26,49,51,55,56,64,65). Injuries to this structure have been termed pulley lesions (1,16,26,51,65).

Tendon fibers from the subscapularis merge with the transverse humeral ligament and extend across the floor of the bicipital groove, fusing with those of the supraspinatus tendon into a sheath that encompasses the biceps tendon (2,49,57,64).

The biceps, (meaning “two headed”), muscle consists of a short head and long head and goes from the shoulder to the elbow on the front of the upper arm. The muscles forming the short and long heads stay separate until just above the elbow where they unite (1,20,21,24,25,63). Tendons attach muscles to bones; Two separate tendons (the proximal tendons) connect the upper part of the biceps muscle to the shoulder, and one tendon (the distal tendon) connects the lower part of the biceps muscle to the elbow. (Proximal refers to closer-to-body, or “upper”, while Distal refers to farther-from-body, or “lower”.)

The short head of the biceps connects at the shoulder on the corocoid process (a small bony knob of the scapula just in from the front of the shoulder) and passes under the deltoid (shoulder muscle) (14,51,63,64).

The long head of the biceps attaches to the top of the glenoid at the supraglenoid tubercle and the posteriorsuperior labrum, though the main labral attachment varies, arising from the posterior, the anterior, or both aspects of the superior labrum (14,20,21,51,63,64). Beginning at the glenoid, the tendon of the long head of the biceps (LBT) travels down the front of the upper arm and runs within the bicipital groove (between the greater and lesser tuberosities) on the proximal end of the humerus where it is held in place by the transverse humeral ligament (THL) (14,51,59,60,61,63,64). It is here that this “slip” phenomenon of the LBT seems to occur.

Of the ten local athletes who had this problem, (6 female, 4 male), in nine the tendon had slipped forward (anteriorly) and in one, a female, the tendon slipped behind (posteriorly).

CAUSE:

A definitive cause is uncertain. None of us can recall a specific moment in which we “became injured.” While we are all avid CrossFit’ers, most of us participate regularly in other physically demanding sports, activities and occupations. We could have sustained our injuries through any number of means.

As for the actual “causal mechanism” that allows the tendon itself to shift out of place, that is unclear without an MRI, Contrast MRI or Arthroscopy. The exact nature and degree of injury to these athletes has yet to be diagnosed through such means, though I would suspect they vary.

Considering the LBT often predominantly attaches to the glenoid fossa at the labrum, this injury could be related to “SLAP tears” (superior labral tear from anterior to posterior) that sometimes afflict “throwing motion” athletes, such as Tennis, Baseball, Volleyball, Water Polo, or those who’ve suffered a bad fall. SLAP tears often occur where the biceps tendon anchors to the labrum. Tears in this region of the labrum are generally slow to mend as the superior and anterosuperior parts of the labrum have less vascularity than do the posterosuperior and inferior parts, and the vascularity itself is limited to the periphery of the labrum (21,52,51). What this means is less blood flow to the injured area and slower transport of needed healing elements carried within the blood, thus limiting the body’s ability to effectively and efficiently repair the injured area.

Certified Sports Massage Therapist, Sara Bosinger of Touch Therapy, suspects that the “tendon slip” phenomenon could be caused by a lesion, fray, tear or stretch of the superior labrum at the insertion point of the long-head biceps tendon, thus causing the tendon to “slip” since it’s not being held correctly. While this is perfectly logical and goes hand-in-hand with the SLAP tear phenomenon, it crossed my mind that since where the LBT sits in the bicipital groove is held in place by the transverse humeral ligament (THL), and the tendon slips out of this groove, that a lesion, fray, tear or stretch could also be at the THL. However, current research suggests the THL overlying the bicipital groove is no longer considered as a crucial stabilizing structure unless the medial coracohumeral ligament is torn (3,48,51). Some research even questions the existence of the THL altogether (53,59). Recent studies indicate there is no distinct THL (53,59,60,61), rather, support of the LBT within the bicipital groove is likely a fibrous tissue extension of the subscapularis tendon (53,59). Thus, if you choose to get a Contrast MRI to evaluate your subluxing LBT, examining the subscapularis along with the rest of the ligamentous pulley system and labrum should also be considered.

The bicipital groove itself has a wide variance in the angle of its walls, but 70% fall within a 60° to 70° range (14,23,25,26,50). During internal and external rotation of the arm, the biceps tendon swings from one acute angle to the other (19,20,21,50,51), thus, in a shallow bicipital groove, the possibility of the tendon slip is potentially greater as the tendon has a tendency to force it’s way over the greater or lesser tuberosity (34,35,40,50,51,53). In contrast, if the bicipital groove is narrow and tight, the constant pressure on the tendon may cause tendonitis or even rupture of the tendon (3,23,43,48,50).

As it turns out, this biceps tendon slip injury is not uncommon in athletes and is in fact one of three common injuries to the biceps tendon, including Biceps Tendonitis and complete Biceps Tendon Rupture. This biceps tendon slip phenomenon even has an official medical diagnosis; “Biceps Tendon Subluxation”. Subluxation of the long head biceps tendon (LBT) from the bicipital groove is a common causes of shoulder disability in the throwing arm of an athlete (50).

There is no single definitive precursor to Biceps Tendon Subluxation, there are several causes such as direct physical trauma (such as a fall or crash), repetitive throwing motions, SLAP tears and tears to the ligamentous pulley system of the shoulder, such as at the subscapularis tendon, coracohumeral ligament, superior glenohumeral ligament or supraspinatus tendon. All can lead to a subluxation. For the ten of us who had this injury, I’m sure the actual causal mechanism of the tendon slipping out of place varies athlete to athlete, as likely does the origin of the injury itself.

SYMPTOMS:

Generally speaking, subluxation of the long head biceps tendon from the bicipital groove has characteristic symptoms; pain, decreased range of motion, pain on throwing that is relieved by rest, a palpable snap at a certain point in the arc of motion, and pain with pressure to the front of the shoulder (50, 54). Common signs are tenderness over the bicipital groove, pain and occasionally tenderness or swelling over the front of the shoulder, pain upon pressure to the front of the shoulder and a reproducible pop in rotation of the humeral head (50, 54).

However, the symptoms of our injuries varied greatly. As is consistent with labral tears and other injuries to the shoulder, our symptoms ranged as far as pain, location, weakness, popping or clicking in the shoulder, decreased range of motion and loss of strength. In some, the pain was an occasional dull throbbing ache in the joint that could be aggravated by strenuous exertion or even mundane activities, yet in others the pain was constant and severe and we could physically press on areas that would hurt with pressure, usually in the front of the shoulder where the tendon had slipped, though in some, on the top of the shoulder. SLAP tears, in most cases, will also yield inflammatory changes around the biceps tendon origin. The degree of our impaired mobility varied just as much as the pain, and many of us had difficulty sleeping, especially on our side.

DIAGNOSIS:

If you know exactly what to feel for, I suppose it’s possible to “self-diagnose” whether your tendon is out of place or not. Manipulating it back into place, however, is highly unlikely, otherwise you would have done it already. I would suggest going to a Certified Sports Massage Therapist or other such professional familiar with this problem. If they are good at what they do and know what to look for, they should easily be able to tell whether it has slipped or not. If it has, they will likely be able to manipulate it back into place.

As for diagnosing the the actual causal mechanism or root injury that leads to the subluxation, that will likely not be diagnosed without professional medical help. SLAP tears, for example, will likely not be diagnosed without a Contrast MRI or exploratory Arthroscopy. SLAP tears don’t show up well on standard MRI’s and the pain generated by them can mimic many other shoulder problems. Overall, they are very difficult to diagnose.

PROGNOSIS:

Regardless of cause or duration, we all found marked relief in having the biceps tendon manipulated back into place and secured with Kinesio Tape while it heals. This has worked very well, whether our injury was recent or chronic. THAT is why I am writing this; because each of the athletes suffered significantly from their injury, yet each found immediate comfort (less pain, increased ROM) through this simple process and avoided both surgery and cortisone shots. We were able to resume our normal training to some extent, if not completely, within 10 days.

Some of us, luckily, were only suffering for a few weeks and it was a relatively easy/fast fix that our tendon was put back into the bicipital groove. Mine was reset within 5 minutes, though was quite sore for several days afterwards. Two of the ten athletes, however, suffered with their shoulder injury for nearly a year. One, Jason Nee, great athlete and local Firefighter, had been going to physical therapy for several months with no relief what-so-ever, and has since been counseled by his doctor to “just get a cortisone shot”. I recommended he go see Sara, considering that physical therapy had been to no avail. ...And so he did. Sure enough, his bicep tendon was out as well. Considering that Jason Nee’s tendon had been out for so long, it took Sara a good half hour to work it back into place, but when she did, Jason said that he had immediately noticeable improved mobility and reduced pain. As with mine, it was very sore for several days after (his, closer to a week). The other athlete, Rachel Sherer, who had been dealing with her injury for close to 9 months had similar results as Jason’s. She even called me afterwards and said, “Jason, I’m fixed.--It doesn’t hurt anymore.” (That was the best phone call ever.) Again, THIS is why I am writing this. Some of these athlete’s have been dealing with their shoulder injuries for months with little to no relief, not even from physical therapy, yet each found marked relief once the tendon was put back into place.

For myself and the other athletes who’s injuries were recent, our healing process has been very steady once the tendon was put back into place, Kinesio Taped, and treated with some intensive and frequent Cryotherapy. We’ve all pretty much resumed our normal training. I chose to lay off of pulling/pushing movements or any significant overhead work other than Push-Jerk and Handstands for a week to help facilitate the healing process. This seems to have worked very well so far and I have since reintroduced all my normal strength-&-conditioning movements with no problem thus far.

However, for Jason Nee and Rachel Sherer, their recovery has been a little slower. Both suspect that the tendon may have slipped back out, but are not really sure to what extent, (if at all). Whether this is do to the fact that their tendon was out of place for a much longer period, or is due to them having a more significant injury than the rest of us, will likely not be determined without further professional medical help. In Jason Nee’s case, a Contrast MRI or Exploratory Arthroscopy will likely be needed.

PREVENTION:

Without knowing exactly how we sustained our injuries, it is difficult to outline exactly how to prevent it. However, in a recent post, (and plenty of posts before it) Sam Radetski mentioned several elements that can serve as surefire ways to minimize risk of injury.

Be conscious of good technique when driving hard during a wod or trying to beat the person next to you. A little care when chasing those exhilarating PR’s or trying to obtain that sought-after “first place” title can help keep you in the gym over the long haul.

Consistent Mobility Work and proven Recovery Techniques such as PNF Stretching, Foam Rolling, Trigger-Point Therapy, Cryotherapy and the occasional Ice Bath can all play a critical roll in helping you optimize the way your body moves, performs and recovers, not simply in a wod, but in life. Consider it as “basic maintenance” for the body. As Sam said, “Hot joints and muscles that are left untreated develop into injuries.” I HIGHLY recommend everyone follow Kelly Starrett’s MobilityWod. 4-10 minutes a day of disciplined mobility work will not only improve your performance and facilitate your recovery, but will minimize your risk of injury.

Nutrition plays a critical role in your health and fitness for more reasons than I can list here. Nutrition serves as the absolute foundation for everything else we are trying to achieve, (Recall Coach Glassman’s “A Theoretical Hierarchy Of Development”; [a.k.a.; “the fitness pyramid”] in the June 2002 issue of the CrossFit Journal, “What Is Fitness?”). If you have a weak foundation, whatever you build upon it will suffer. Optimizing your nutrition will simultaneously maximize training results and minimize injury risks.

Every element within the realm of Prevention can be pivotal to your continued success, perhaps every bit as important as doing the wods themselves. Exercising diligence within these areas can all serve to minimize your risk of injury and help keep you participating in this sport of fitness that we’ve all grown to love.

If you are prone to LBT subluxation; popular with swimmers and water polo players, this strap is designed to help keep the biceps tendon in the groove via compression:

http://www.cho-pat.com/products/product.php?product_type=6

For coaches, I would also suggest watching the Wellesley shoulder lecture:

http://vimeo.com/9749229

CONCLUSION:

While it is true that each of the injured athletes are avid CrossFit’ers, most of us regularly engage in other physically demanding sports, activities and occupations, and none of us can recall at what point exactly we sustained our injuries. Some may jump to the conclusion that CrossFit must be the origin of our injury, ...and while that is possible, it should be noted that I have been CrossFit’ing for 15 years and had never before obtained this injury. In reality, it is the fact that we all CrossFit and are a part of this amazing community that allowed us to network, seek the right path, and finally find a solution to our injured shoulder and resume our normal training. ...Had we not been a part of the CrossFit community, ...we may never have found a solution.

If you suffer from a “bad shoulder”, regardless of how long it’s been, consider having it checked for an LBT Subluxation before doing months of physical therapy or settling for a cortisone shot. I’m not saying this will work for everyone. The nature of your shoulder issue may be nothing at all like I am describing. However, if it is the problem you are suffering from, a simple fix of having it put back into place can yield immediate and marked relief and may have you back to your regular training or sport within a very short time. ...Once again chasing all those “PR” goals you’ve set for yourself.

...If you are local, or even semi-local, I highly recommend Sarah Bosinger of Touch Therapy; Certified Sports Massage Therapist and Certified Kinesio Taping Practitioner (touchtherapy831@sbcglobal.net, 831-818-0477). She is absolutely amazing.

Jason Highbarger

The ten confirmed local athletes with this issue:

Jason Highbarger

Ronnie Boose

Jason Nee

Troy Miller

Danielle Winters

Melanie Desere Turowski

Rachel Sherer

Paige Nutt

Narine Kadekian

Helen O’Brien

I personally suspect seven others of having this same issue:

Beau Frasier

Ashley Collins (Now Confirmed)

Shawn Smith

John Van Every

Dan Pfeifer

Jesse Martin Ashe

Beth Albalos

References:

1. Jost B, Koch PP, Gerber C. Anatomy and functional aspects of the rotator interval. J Shoulder Elbow Surg 2000; 9:336-341.

2. Bennett WF. Subscapularis, medial and lateral coracohumeral ligament insertion anatomy: arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy 2001; 17:173-180.

3. Slatis P, Aalto K. Medial dislocation of the tendon of the long head of the biceps brachii. Acta Orthop Scand 1979; 50:73-77.

4. Cooper DE, O’Brien SJ, Warren RF. Supporting layers of the glenohumeral joint: an anatomic study. Clin Orthop 1993; 289:144-155.

5. Clark J, Sidles JA, Matsen FA. The relationship of the glenohumeral joint capsule to the rotator cuff. Clin Orthop 1990; 254:29-34.

6. McFarland EG, Kim TK, Banchasuek P, McCarthy EF. Histologic evaluation of the shoulder capsule in normal shoulders, unstable shoulders, and after failed thermal capsulorraphy. Am J Sports Med 2002; 30:636-642.

7. O’Brien S, Neeves MC, Arnoczky SP, et al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990; 18:449-456.

8. Ferrari DA. Capsular ligaments of the shoulder: anatomical and functional study of the anterior superior capsule. Am J Sports Med 1990; 18:20-24.

9. Burkart AC, Debski RE. Anatomy and function of the glenohumeral ligaments in anterior shoulder instability. Clin Orthop 2002; 400:32-39.

10. Nobuhara K, Ikeda H. Rotator interval lesion. Clin Orthop 1987; 223:44-50.

11. Edelson JG, Taitz C, Grishkan A. The coracohumeral ligament: anatomy of a substantial but neglected structure. J Bone Joint Surg Br 1991; 73:150-153.

12. Neer CS, 2nd, Satterlee CC, Dalsey RM, Flatow EL. The anatomy and potential effects of contracture of the coracohumeral ligament. Clin Orthop 1992; 280:182-185.

13. Harryman DT, Sidles JA, Harris SL, Matsen FA. The role of rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992; 74:53-66.

14. Vangsness CT, Jr, Jorgenson SS, Watson T, Johnson DL. The origin of the long head of the biceps from the scapula and glenoid labrum: an anatomical study of 100 shoulders. J Bone Joint Surg Br 1994; 76:951-954.

15. Bennett WF. Visualization of the anatomy of the rotator interval and bicipital sheath. Arthroscopy 2001; 17:107-111.

16. Walch G, Nove-Josserand L, Levigne C, Renaud E. Tears of the supraspinatus tendon with “hidden” lesions of the rotator interval. J Shoulder Elbow Surg 1994; 3:353-360.

17. Itoi E, Berglund LJ, Grabowski JJ, Naggar L, Morrey BF, An KN. Superior-inferior stability of the shoulder: role of the coracohumeral Ligament and the rotator interval capsule. Mayo Clin Proc 1998; 73:508-515.

18. Field LD, Warren RF, O’Brien SJ, Altchek DW, Wickiewicz TL. Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 1995; 23:557-563.

19. Nidecker A, Guckel G, Von Hochstetter A. Imaging the long head of the biceps tendon: a pictorial essay emphasizing magnetic resonance. Eur J Radiol 1997; 25:177-187.

20. Itoi E, Kuechle DK, Newman SR, Morrey BF, An KN. Stabilising function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993; 75:546-550.

21. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994; 22:121-130.

22. Neer CS, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972; 54:41-50.

23. Warner JJ, McMahon PJ. The role of the long head of the biceps brachii tendon in superior stability of the glenohumeral joint. J Bone Joint Surg Am 1995; 77:366-372.

24. Ting A, Jobe FW, Barto P, et al. An EMG analysis of the lateral biceps in shoulders with rotator cuff tears. Presented at the Third Open Meeting of the Society of American Shoulder and Elbow Surgeons, San Francisco, Calif, January 21–22 1987.

25. Yamaguchi K, Riew KD, Galatz LM, Syme JA. Biceps activity during shoulder motion: an electromyographic analysis. Clin Orthop 1997; 336:122-129.

26. Weishaupt D, Zanetti M, Tanner A, Gerber C, Hodler J. Lesions of the reflection pulley of the long biceps tendon. Invest Radiol 1999; 34:463-469.

27. Rowe CR. Recurrent transient anterior subluxation of the shoulder: the “dead arm” syndrome. Clin Orthop 1987; 223:11-19.

28. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am 1981; 63:863-872.

29. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability: two to five-year follow-up. J Bone Joint Surg Am 2000; 82-A:991-1003.

30. Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 1998; 6:65-72.

31. Selecky MT, Tibone JE, Yang BY, McMahon PJ, Lee TQ. Glenohumeral joint translation after arthroscopic thermal capsuloplasty of the rotator interval. J Shoulder Elbow Surg 2003; 12:139-143.

32. Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior inferior translation of the glenohumeral joint. Am J Sports Med 1992; 20:675-685.

33. Le Huec JC, Schaeverbeke T, Moinard M, et al. Traumatic tear of the rotator interval. J Shoulder Elbow Surg 1996; 5:41-46.

34. Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999; 8:644-654.

35. Walch G, Nove-Josserand L, Boileau P, Levige C. Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998; 7:100-108.

36. Berlemann U, Bayley I. Tenodesis of the long head of the biceps brachii in the painful shoulder: results in the long term. J Shoulder Elbow Surg 1995; 4:429-435.

37. Chung CB, Dwek JR, Cho GJ, Lektrakul N, Trudell D, Resnick D. Rotator cuff interval: evaluation with MR imaging and MR arthrography of the shoulder in 32 cadavers. J Comput Assist Tomogr 2000; 24:738-743.

38. Ho CP. MR. Imaging of rotator interval, long biceps and associated injuries in the overhead-throwing athlete. Magn Reson Imaging Clin N Am 1999; 7:23-37.

39. Grainger AJ, Tirman PF, Elliot JM, Kingzett-Taylor A, Steinbach LS, Genant HK. MR anatomy of the subcoracoid bursa and the association of subcoracoid effusion with tears of the anterior rotator cuff and the rotator interval. AJR Am J Roentgenol 2000; 174:1377-1380.

40. Farin PU, Jaroma H, Harju A, Soimakallio S. Medial displacement of the biceps brachii tendon: evaluation with dynamic sonography during maximal external shoulder rotation. Radiology 1995; 195:845-848.

41. Rokito AS, Bilgen OF, Zuckerman JD, Cuomo F. Medial dislocation of the long head of the biceps tendon: magnetic resonance imaging evaluation. Am J Orthop 1996; 25:314, 318-323.

42. Seeger LL, Lubowitz J, Thomas BJ. Case report 815: tear of the rotator interval. Skeletal Radiol 1993; 22:615-617.

43. O’Donoghue DH. Subluxing biceps tendon in the athlete. Clin Orthop 1982; 164:26-29.

44. Zarins B, McMahon MS, Rowe CR. Diagnosis and treatment of traumatic anterior instabilty of the shoulder. Clin Orthop 1993; 291:75-84.

45. Boardman ND, Debski RE, Warner JJ, et al. Tensile properties of the superior glenohumeral ligament and coracohumeral ligaments. J Shoulder Elbow Surg 1996; 5:249-254.

46. Cole BJ, Rodeo SA, O’Brien SJ, et al. The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001; 390:129-137.

47. Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder: role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am 1989; 71:1511-1515.

48. Petersson CJ. Spontaneous medial dislocation of the tendon of the long biceps brachii: an anatomic study of the prevalence and pathomechanics. Clin Orthop 1986; 211:224-227.

49. Werner A, Mueller T, Boehm D, Gohlke F. The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval: a histoanatomic study. Am J Sports Med 2000; 28:28-31.

50. O’Donoghue, Don H. M.D. Subluxing Biceps Tendon In The Athlete, Clinical Orthopedics and Related Research, April 1982, Volume 164, pp:2-312;

51. Yoav Morag, MD Jon A. Jacobson, MD Gregory Shields, MD Rajiv Rajani, BS David A. Jamadar, MB, BS Bruce Miller, MD Curtis W. Hayes, MD, MR Arthroscopy of Rotator Interval, Long Head of the Biceps Brachii, and Biceps Pulley of the Shoulder Radiology RSNA, 2005

52. DE Cooper, SP Arnoczky, SJ O'Brien, RF Warren, E DiCarlo and AA Allen, Anatomy, histology and vascularity of the glenoid Labrum. An anatomical study, Hospital for Special Surgery, Cornell University Medical College, New York City, N.Y. The Journal of Bone and Joint Surgery, Vol 74, Issue 1 46-52, Copyright © 1992 by Journal of Bone and Joint Surgery, Inc

53. Robert W. Pettitt, PhD, ATC, CSCS*; Scott R. Sailor, EdD, ATC†; Gary Lentell, DPT†; Cary Tanner, MD ‡; Steven R. Murray, DA § Yergeson's Test: Discrepencies in Description and Implications for Diagnosing Biceps Subluxation, Athletic Training Education Journal, Volume 3, Number 4, Oct-Dec 2008

54. Elsevier Science (USA), 2003

55. Joseph P. Iannotti, Gerald R. Williams, Jr., Disorders Of The Shoulder, Diagnosis & Management, 2007.,

56. Jon J. P. Warner, Joseph P. Iannottie, Evan L. Flatlow, Complex and Revision Problems in Shoulder Surgery, 2005.

57. William F. Bennett, M.D., Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy, Arthroscopy, The Journal Of Arthroscopic And Related Surgery, Volume 17, Issue 2, Pages 173-180, February 2001

58. www.eorif.com/Shoulderarm/Shoulder%20anat/Shoulderanatomy.html

59. MacDonald K, Bridger J, Cash C, Parkin L, Transverse Humeral Ligament: does it exist?, PubMed Clinical Anatomy, New York, NY, 2007, August 20 (6):663-7

60. Gleason PD, Beall DP, Sanders TG, et al. The Transverse humeral ligament: a separate anatomical structure or a continuation of the osseous attachment of the rotator cuff? Am J Sports Med 2006:34(1):72-7

61. MacDonald K, Bridger J, Cash C, Parkin I. Transverse humeral ligament: does it exist? Clin Anat 2007;20(6):663-7.

62. Richer, Paul, M.D., Artistic Anatomy, 1986

63. Martini, Frederic H, Ph.D., Timmons, Michael J, M.S., Human Anatomy: Second Edition, 1997

64. Zlatkin, Michael B., MRI Of The Shoulder, Second Edition, 2003

65. Yoav Morag, MD, Jon A. Jacobsen, MD, Gregory Shields,, MD, Rajiv Rajani BS, David A Jamadar, MB, BS, Bruce Miller, MD and Curtis W.Hayes, MD, MR Arthrography of Rotator Interval, Long Head Biceps Brachii, and Biceps Pulley of the Shoulder, Radiology RSNA, 2005

66. OrthoPod, Shoulder Anatomy; A Patient's Guide to Shoulder Anatomy