(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

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