Overhead Shoulder Pain: Stop Chasing Fixes—Build Tolerance Instead | Dr Tyler Nelson

Ageless Athlete Recording - Dr Tyler Nelson - Shoulders & Scapula
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Speaker 2: [00:00:00] Two years ago when we met, I had started asking this, icebreaker question, which has kind of become the signature of the podcast, which is I always ask people where they are right now.

So tell, where are you right now and what did you have for breakfast this morning? 

Speaker: Ooh. I had, uh, English tea, English breakfast, tea, which is my favorite with two, probably a tablespoon of sugar and some heavy whipping cream instead of half and half. Just like, maybe a tablespoon of that. I don't measure that.

I'm just guessing. uh, where I'm at right now, I've re my job is very similar than the last time we talked. I do a lot of remote consulting with climbers around the world with elbow, shoulder, wrist, finger injuries, mostly finger injuries, but lots of upper extremity, left shoulders. Number two.

And then I did a lot of international teaching last year, which I'm gonna do this year for courses that I offer specifically, like upper extremity rehab course. And then I've been baking, lately I've been learning to make croissants, which has been a [00:01:00] surprisingly challenging thing to get right. 

Speaker 2: Baking croissants is extremely challenging, but what I find surprising about your answer is not that you are baking croissants, but where are the donuts that are, because Oh yeah.

Chinese for class, you talked about this, allegiance to donuts. 

Speaker: So I'm a trader to the donut. Uh, the, the donut lock off kind of simmer down after COVID. Right. That was like a 2018 to 2020 thing. And when I traveled to teach, people still remembered the donut thing, and so they will bring donuts to the courses, which is, you know, very fun.

I realized that like 43, I have never baked anything in my life. Like, I literally had never baked anything.

Speaker: I was like, I've never even made a box cake. I was like, we've been watching the Great Bridge Baking Show, and the kids. And so it's like, that's kind of sad. I was like, that's kind of sad. I've never baked anything. And so for whatever reason, maybe athletes are like this, I just went for [00:02:00] like. The hardest thing to make, which is cro.

That's 

Speaker 2: true. yes. 

Speaker: So I was like, I'm gonna learn how to make croissants 'cause I like croissants and they, they look cool. It's like been maybe 15 attempts, iterations of making croissants and I still can't get it. Right. 

Speaker 2: Oh my God. yeah. I tried baking croissants over COVID, like I go into baking as well, and I used to balk at paying, I don't know, $6 a croissant.

And, and now there are more, before I, I tried baking them, but now if I go to a, a nice pastry shop and I just pay whatever they ask for in Oh, yeah. Oh, it makes sense. They earn every cent because that is precision and labor. They deserve every penny. 

Speaker: Yeah, it's definitely a lot of work.

Tyler, it was an honor to have you on the show during our early season. It was almost two years the date you came on the podcast, and it has been one of the most loved episodes you've had on Ageless Athlete And, preparing for today's conversation.

Speaker 2: I [00:03:00] went back and looked at my notes and, you know, we spoke about tendon loading, we spoke about strength training. We challenged some beliefs with resting and over resting, and this time we reached out. You said you had something new to share. tell us what do you believe now that you didn't believe two years ago?

Speaker: I don't know. It's something that I didn't believe. It's more like in preparation for doing this new upper extremity course that I'm gonna be teaching, like internationally and, and nationally finding the most, uh, I guess unstudied and over-emphasized components of the musculoskeletal system. And specifically it was looking at shoulder pain because I talked to so many athletes with shoulder pain and they go see a healthcare provider.

And the healthcare provider likes to attribute a lot of their pain to the scapula and how the scapula is moving and that the scapular is winging. And, , it's very [00:04:00] mechanically. Plausible for that description, but there's not really any evidence for it. And there's a couple really good papers that challenge that.

And so essentially I was like, that's something that would be interesting for people more broadly to hear, because a lot of people are walking around being overly concerned with their posture and whether that's changing over time and not being attributed to reducing their shoulder pain. So it's, I've known those things for a while.

It's just like, you know, you dig into something and you're like, oh, I should share that with a bunch of people. And it's obviously hard to do that through social media platforms. That tends to be kind of annoying. So 

Speaker 2: data, interesting focus on the scapula. And maybe I can ask a preface question. when over at Athletes, at least in my worldview, myself and others, I know we start experiencing.

Issues with using our shoulders. We don't immediately, or at least I don't immediately think of my scapula as being either a cause or a, a central point of [00:05:00] this issue I might be having. So why the scapula and why now? 

Speaker: the scapula is incredibly important because the ability to transfer load, like in a rock climber from their fingers through their core, has to go through the attachment point.

And the scapula essentially is the attachment point of the hand to the torso. And so when someone has a pain complaint and they have overhead pain and there's a whole motor control theory behind pain complaints in the shoulder, which would attribute a lot of the disconnect there or. Leak, let's say in the mechanical chain attributed to the control of the scapula or the range of motion of the scapula.

And so there's a whole kind of offset of people that are attributing that to that particular mechanism. And when we tell people that, the hard thing of telling someone that is, then they try and think that prevention is consistently managing that scapular motion. Right? And so it's, it's just fundamentally kind.

I mean, it makes sense and I understand why people do that, but the evidence for it [00:06:00] is that it does help people and reduces their symptoms if we retrain how they control their glenohumeral joint through movement, moving the scapula, et cetera. But it's not really because it's changing anything structurally about the scapula itself.

Does that make sense? 

Speaker 2: it does, but I also, I, I'm still trying to wrap my head around. Where the scapula fits into this broad picture of shoulder complaints and shoulder issues. Because, because Yes, yes. we have somebody, let's say, who's listening, who's got some shoulder issues, and they have been told that they have some ringing.

Maybe they lack stability. and when do people start actually paying attention to their scapula as being either, a visual marker or? uh, something more than that where it is actually causing some loss of [00:07:00] function, some impairment in the ability to do this word. 

Speaker: So an easy way to think about it would be, you know, if someone has shoulder pain on the tip of the shoulder or the front front tip of the shoulder and they just bring their arm straight overhead and the top part of that motion ha creates some sort of pain sensation.

If they, if someone can be queued to think about gliding and inferior translating the scapula down as they go overhead, they will have an increased range of motion. And so people have a pain complaint and that intervention is applied to the individual and they learn to be more conscious about it and they train that depression motion, those athletes can immediately have less soreness when they reach overhead.

And so the ability to. Do specific movements for them in sports they wanna get back to the pain can be changed with just simple cues and movement modifications and, you know, different timing and different loads, et cetera. And that can be pretty helpful for people. But the reality is, is [00:08:00] we don't really understand why that helps people get back to normal function and pain.

We, that's where the camps are different. Did they get stronger? Did they learn a new motor control? Is their motor control better? We don't really know why, but we definitely know why. Well, we definitely know that those interventions don't really change the, the static position of the scapula, which is not that important.

And there's huge variability between individuals, just in general. And we don't have good measurement, standardized measurements to assess scapular motion. And so it's really just like. More generally giving people a breath of fresh air and not be so worried and obsessed with what the scapula is doing with all of their things.

And that's very common in climbing. When people do hanging, we'll see videos all over the internet of this is how you properly hang board. You have to, inferior glide your traps. You have to activate the inferior traps. And so essentially what it, and that's not that's a bad thing, it's really just that it's not always necessary and we don't understand maybe why it's helpful, but it's really just an overload thing.

So it's more [00:09:00] kind of the same that we talked about with the elbow is if people are consistently overloading their shoulder, that's when pain complaints are most common. and in the shoulder, rotator cuff injuries are the most common. But ultimately, like we have to find a way to modify their activities.

And there's all these different ways we can do it, and they all have pretty equal effectiveness, but it's not really because we're changing how the scapula functions and moves.

Speaker 2: I understand. Let me ask something from my own experience. I experienced some of that scapular winging myself, and I also experienced some range of motion with, being able to raise my arm above a certain height. 

Speaker: Mm-hmm. 

Speaker 2: With my injured shoulder. And I've heard similar complaints anecdotally from other climbers and surfers I speak with.

In my case, the scapula comes into my conversation when I find that after a long surf session, my [00:10:00] scapula tends to almost, move places. And maybe that's what's called scapular winging. And. it tends to push my shoulder blade out, and then I sometimes in extreme situations when, my shoulder's really sore, I have to manually almost pull that shoulder back in.

And so I have been told that I do have some scapular, for lack of a better word, like, just scap issues. I have either a scapula or I have a scapula that tends to move a lot. what you are helping us understand is that, the problem that I have? Is that something to do with scapular strength?

Is it scapular posture? Is it scapular engagement? What do you think is going on with somebody who, who experiences these kinds of issues that might or might not be related to, uh, the scapular is. healthy and how it's moving. 

Speaker: The term that people will use is called scapular dyskinesis, or dyskinesia, which is essentially referring to an [00:11:00] abnormal movement of a particular scapula on an individual.

And as just mentioned, there's not good standards in the literature for what normal is, but we do know that there's a wide variety of scapular positions and movements and ratios with their shoulder joint between individuals. So it's really hard, just telling someone that they have scapular dyskinesia, they're like, oh shit, I guess I gotta like, I guess I got something wrong with my position, or something wrong with my shoulder, and I'm going to correct that with a particular exercise.

Making my inferior trapping gauge more, making my serus anterior better set my scapula. The literature shows when they compare motor control exercises that are targeting structural changes versus just general strength training, the outcomes are the same. The pain up front is a little bit quicker with motor control exercises, but we don't really know why.

But a lot of that is if you have a [00:12:00] fearful movement and we give you something that's largely focused on a joint that's a little bit more proximal, which is the scapular thoracic joint, it just makes people a little bit less fearful. They still can move their shoulders, so they get all the benefits of general movement.

They don't provoke the so tissue maybe in the shoulder itself. And so there is benefit to doing those things, but we don't really understand why. But the other thing that I would add is once your shoulder feels normal, your shoulder pain, let's say, has gone away. You don't need to keep doing those other exercises, motor control exercises as a preventive strategy.

Because the one thing you mentioned is, say when I go to a long surfing session or when I do a lot of surfing, that's a volume thing that's not really, you know, essentially it's not that your, your shoulder can, in your scap that can be trained in a way that will allow you to tolerate an indefinite amount of volume that doesn't exist.

Right. And so it's really, understanding the individual and what they want to get back to and what they're used to doing, and how many days a week, like all that stuff matters. And so just like a [00:13:00] generic cookie cutter, you gotta do this for the scapula is super ineffective, but it's also, you know, frustrating for people with shoulder pain.

Speaker 2: Right on. So you're saying that maybe there's been like, an over-indexing on the scapula as both maybe a source of. Shoulder pain or shoulder range of motion or lack of shoulder range of motion. And also this overemphasis on the scapula as, as something that needs to always be kinda in focus for like long-term shoulder health.

Speaker: Yeah. The, the basic like motor control strategies where people do like scapular queuing and they set their scapula and they do like the pushup plus and they do those exercises that you're probably familiar with. Mm-hmm. Those are okay and fine with you in the acute stages when someone's very sore, but training them indefinitely is not preventive for athletic injuries.

and that applies to everything like we talked about with the elbow. You can't prevent an injury with more low intensity exercise. It's just not that there's no evidence to support that actually works. It always has to be [00:14:00] customized for the individual. It always needs to be progressed based on their goals.

It always needs to be very much. Have to do with their preferences as well. this idea that, the, there's a postal fix for it just is fundamentally not true. And for people to know that is like, oh, cool. That's a good thing. I don't need to worry about it. I'm someone that dealt with that, like when I was a kid, like there's, my thoracic spine is pretty, pretty, not hyper kyphotic, but it's definitely pretty sharp.

My upper back. And my scapulas also are like kind of more rounded naturally. And I look just like my dad. My dad looks the same way. And so I've always had like rounded shoulders my whole life, even before I was a climber. And so I, he actually used to make me wear a brace when I was a kid, which is like a structural brace that would like pull your shoulders back to try and fix your posture, which is a terrible idea.

Like, it's so unhelpful and unnecessary, but like, so I've always kind of had that in the back of my mind as to like, oh, my, my posture is a problem. And, but the reality is I've never had shoulder pain. My shoulders are, my joints are very stiff, you know, more [00:15:00] generally. So they don't have a big range of motion, but that's usually pretty protective for a joint.

'cause I don't expose the end ranges of my joint as much as someone else because I really can't access a lot of those ranges of motion. And so I would be a good example of someone that you would say has maybe scapular dyskinesia, but that has nothing to do with like, the predisposition for having shoulder pain or symptoms.

Does that make sense? 

Speaker 2: It absolutely, it, it does. you describing that, uh, makes it easy to follow. And you are correct, as you were talking, I, I was just remembering, like social media and the internet is just like full of, just rife with instructional videos on like scapular stability and.

I'm sure, many people listening here, they follow or have followed some of those protocols with, scapular strengthening and, uh, some of the things you described. And what I'm learning is, or what you're sharing is that beyond a certain point, those are not so effective. Like you can do the retraction and the protraction and like, you know, the hanging scapular, like [00:16:00] isolation exercises, but like beyond a certain point they are not really helping because, 

Speaker: and those are, those are just basic exercises, right?

So it's like, I think I am a fan of like having a holistic program that does train, you know, more stabilizing muscles. I think that's just good basic strength conditioning stuff, but the narrative behind it that it's going to be reductive for injuries or there's an, there's a perfect way to do a movement for an individual.

that's just fundamentally confusing for people. And most people that I talk to now are more confused by information out there than they are helped by it. Right? There's so many, so much information. They're like, I don't really know what to do. Please like, tell me what to do. Right? And that's when you know, it takes having a really broad knowledge base about mechanics and exercise and pain literature, et cetera, and the psychology of pain to be like, okay, what is it fundamentally that you're trying to get back to?

What are the things that are provocative? What do you have equipment for? What do you [00:17:00] actually enjoy doing? what does your weekly schedule look like? And fundamentally that makes way more sense for rehabilitation than if someone just has shoulder pain and they're like, okay, I need to work on this particular exercise only and it's gonna fix my shoulder pain.

That just misses the big picture. In terms of having them have better load management, which the load management is gonna be the thing that will help their pain go away, regardless of whether it actually fixes a tissue or not, which in the shoulder doesn't really happen that much. 

Speaker 2: Understood. what might also help Tyler is if you could walk us through maybe a couple of case studies of athletes coming to you with shoulder issues, and maybe you could describe to us what are some of the more common issues people complain about?

those symptoms might be and what is this, let's say, evolved treatment plan that you have them go through. 

Speaker: Yeah. So for, for rock climbers, there's a really helpful [00:18:00] paper that was done on asymptomatic climbers. So I think if I'm correct, they did 50 athletes and they MRI both shoulders and they found a really high incidence of labral tears, a very high incidence of rotator cuff tendon tears, high incidence of bicep tendon tendonitis, tendon pathology, and some cartilage degeneration, or surprisingly high percentage of cartilage degeneration.

But the most important thing about this study is these people had no pain in their shoulder. The other thing was they were examined orthopedically with all the special tests that healthcare providers learned to use. They were all functional, and they actually measured their strength in a bunch of different positions, and they were all strong as a non-injured athlete would be, which means that people, these people were walking around and they're probably more stressed now because of the MRI findings.

If they told 'em, I don't really know, but they're like, damn, now I gotta tear my shoulder. Now I gotta worry about it. But those athletes had been performing at, they said elite level, but it wasn't super elite level. I think [00:19:00] it was like they can climb five 11 plus or something, nowadays that's not very elite, but they were regular climbers regularly exposing themselves to overhead positions and all the stress that climbers do, just like you and I.

So fundamentally, that means the MRI findings aren't really that indicative of someone's, you know, actual pain and loss of function. So if someone comes into me, it's very typically one of those things is sore. They're sore on the front of the shoulder, or they're sore on the shoulder, on the side of the shoulder, or they're sore on the backside of the shoulder.

Those are like three very common locations. Typically on the front of the shoulder, the pain is like deep. Someone has a deep pain in their shoulder and they have a really long climbing history. They've done lots of training cycles. They climb really hard, climbing's like their thing, right? The suspicion of a labral tear is relatively high.

If they've had pain that kind of persists and you know, progresses and doesn't seem to go away, like ultimately those athletes depend on like how much they understand strength training, lifting weights, how much they enjoy doing [00:20:00] it, ultimately climbers love to climb more than anything else. And so at some point we have to convince them that they need to modify the amount of volume that they're getting with their climbing and really put some time into recovering, right?

Because the way that we get degenerative tears and rotator cuff is with just a lot of mechanical use, just a lot, lots of repetitions, lots of overhead athletes and swimmers. I don't know about surfers if there's evidence on it, but they do a lot of overhead stuff like swimmers. But the incidence of swimmers having significant rotator cuff tears is really, really high.

Right? And so those athletes still are a very Olympic level, right? So let's say someone comes in, they have like a shoulder pain complaint and they have trouble reaching overhead, right? So they go through what's called the painful arc. They're armed at their side, and they're just going out to the side and they're trying to reach overhead.

And right in the middle between 70 and 90 degrees, they're like, oh, pinch is right there. Right? And so a lot of classic, textbook stuff and language about what that is, is like impingement. You've heard that term. 

Speaker 2: Of course, yes. 

Speaker: people will call that [00:21:00] impingement, and that's kind of an outdated term.

Now, cumulatively, the diagnoses on shoulder pain is more considered rotator or cuff related, shoulder pain. That's a more appropriate term nowadays. But if someone comes in with that presentation, essentially, I want to understand. What they've been doing for the last couple months, what their training has looked like, what kind of supplemental training they're doing.

Are they doing a lot of yoga or Pilates or other activities, you know, and which movements are the most provocative? Priority number one. Priority number one from a rehab standpoint.

So if that person comes in, we want, we need to learn how much they've been loading, how they've been loading, what their regular training habits are, how good their sleep quality is, what their nutritional status looks like, et cetera.

Just basic things about that. fundamentally, it's like what do they want to get back to doing? And for my demographic, it's all I wanna get back to climbing. And so as much as I can, I try and keep them on the wall if possible. And very rarely do I say it's, we probably need to take some [00:22:00] time off climbing, unless there's like an acute tear or something significant.

But ultimately we wanna find a way to give them as much as we can and have them focus on all the things they can do instead of being overly stressed about range of motion right away, about scapular mechanics right away. You know? 'cause ultimately if I assess someone's scapula and I give them all these numbers and range of motion, and I track all this stuff and their pain goes away and I retest those things.

The retesting will be the same. It won't really change. So the question is like, is it really worth doing that? Is it really worth even having that conversation? That's a form of over education that's probably not necessary because an athlete walks into a clinic and they get their scapula evaluated and they leave with a piece of paper that says, oh shit, my right side's 12 degrees less than my left side.

They don't really care. They didn't care before. But now we actually gave them something to worry about, which is, there is some science to say that overed educating is a problem. Like people just want to be supported. They want to be giving some basic direction and they want to be followed up with so they [00:23:00] can understand that someone's there to help back and forth, manipulate training programs for them.

You know, so essentially we, we wanna understand the person and what they want to get back to, and then we wanna make a plan that makes them confident again. The lack of confidence and the pain are tightly interlinked. And so if I can find the things that are the primary drivers of the pain, honestly, all we need to do is modify those things.

We just like, if it's a, and one example would be, it's very common for females, middle aged females to have shoulder pain and have rotator cuff tears. A lot of middle-aged females in my demographic, like sport climbing, and their normal habit is to go to the gym three days a week on a regular routine and do lots of sport climbing.

And typically they're good at vertical climbing because they're flexible and their technical skills are good. And so they do a lot of overhead, overhead positions and a lot of locking off positions. And so ultimately it's like having them understand that they can still climb. All we gotta do is just say, okay, spend more time on steeper [00:24:00] terrain.

Reduce the intensity of the grade to one that's very low power that you can climb comfortably and then maybe cut, if they're doing six routes, cut that down to three routes per session. Give them some things to do before, nine times outta 10 that makes their shoulder pain go away. And so it's like if I, if I did the, the attempt at objectifying the scapula and the mechanics all before that, and then their pain went away, I'm going to attribute all that to, Ooh, we fixed their scapula mechanics.

But that's like not true at all. That doesn't make any sense. And the science would say that's not a reasonable explanation. Right. But, I don't know. Does that make sense the way I described it? 

Speaker 2: That's helpful. Uh, yeah. Just, uh, working with this illustration a great, I think, I think what you described is very common with Yeah.

Middle aged. Climbers and swimmers as well who have been doing this sport for a long time and they start experiencing shoulder issues. the symptoms you described seem to be just, very common. You know, they like raising their, arm above a certain height causes that like [00:25:00] pain and people will describe it as impingement as well.

if I can ask you to take the trouble and explain to us or talk us through what might be some of the current, protocol that you would advise them. So you talked about changing the volume and maybe adapting their training a little bit. In the case of this population, what are some of the other things you might have these.

Athletes go through. You talked about doing some things before and after, and I think this is pretty important because again, there's just so much information out there on how people should treat shoulder pain and shoulder range of motion that I personally get lost. Just trying to sift through those, through some of the chatter I see online on like, because the number of exercises seem to be, you know, more than, I don't know, more than donut shops.

And 

Speaker: more than people have, more than people have time to do. Exactly. More things to do than people have time to do. [00:26:00] So people don't do anything and then they just like only climb because climbing is more fun and climbing's the habit. So if there's so many things to do and they don't understand, they just won't do them 

Speaker 2: a hundred percent Tyler.

And, and there's too many things that just confuse us. And then the other thing that can happen is that. We start doing like this one type of exercise and then we see something else, or here's something else, and then we change to something different. So maybe we don't actually give the first type of exercise enough time to, cause positive change.

Speaker: And that's another like important caveat with rehabilitation is in the shoulders. We don't really have enough convincing evidence to say that getting stronger objectively is necessary to getting better. And that's where there's like the two camps. One is like a motor control theory camp, the other one is like a strength training camp.

But if you put someone through, and I've done this in randomized controlled trials, the outcomes at three months are the same. So that's where like preferences really matter with the individual. If someone, , comes into [00:27:00] me and they're very, um, equipped to assess their, you know, movement mechanics and they're into yoga and Pilates and like to.

Like really feel all the individual muscles and body parts, that's okay to do motor control with those individuals, which would be more of like a, you know, coordination from the hand to the torso kind of intervention. But if it's someone that's like climb hard, I wanna get back to strength training and stuff, they don't really worry about it, then I wouldn't really emphasize it as much with those people.

And the language would maybe be a little bit different how I would communicate that. So like if I had to do like from like the scientific standpoint, if I had to do something for like a basic template that would work for most people if they had overhead shoulder pain, like the demographic we mentioned is like climb at 30 to 40 degrees and do bouldering, you know, maybe two days during your week instead of having three sessions do two days per week instead of the sport climbing example that we were giving and start with two days a week, but still let them go to the gym and climb.

At 40 degrees, you're not reaching overhead as much as you would if it was vertical. You're not locking off hardly [00:28:00] ever, unless you're doing big power moves. But if I reduce the intensity, they're not gonna be doing big power moves. And then just the reason that bouldering works well and that demographic is just easier to look at the holds.

And it's easier to track how much you're doing. You know, you can count, you can approximate the hand moves, you can use the same wall angles, you know, it just, it's just a little bit more accessible in that way for a couple sessions a week separated by two days between climbing sessions before the sessions is usually when I give people like the, what you call rehab strength training stuff.

And the goal there really is to give people enough muscle activity and enough awareness and confidence around the shoulder that they feel ready to get on the wall. And that if they're overhead shoulder pain athletes, then to say, we're probably not gonna do the bottom part of the pull up. We're probably not gonna do the top part of the pull up, but the middle part's probably pretty pain free.

Or instead of doing a pull up, I could just have them do a horizontal pulling motion. They could do a seated row, they could do a bent over row, they could do an inverted row. [00:29:00] All of those would be fine. They could also do something pressing. They could do pushups, they could do pushups on rings. If they had a preference for that, they could do a bench press.

You know, essentially we're just like doing all these activities where they're not doing a lot of overhead activity, right. For finger training, I would have them do block lips from the ground instead of using a fingerboard or going overhead. And then I would give them like two accessory things that would more appropriately target the rotator cuff shoulders, which would either be like a sideline, rear dealt fly, or like a seated, external rotation movement.

And that's it. Maybe like a lateral raise, depending if their shoulder, if their pain was on the shoulder tip, like on the edge of the deloid, they could do a lateral raise as one of those. But like I would say probably 80% of the people that I manage with shoulder pain get a similar kind of structure.

But the actual exercises they do is largely dependent on their equipment, what they like to do. Are they scared to strength train? How often can they, you [00:30:00] know, how is it organized with, does the climbing gym have the equipment? Do they have to go to another gym to do the equipment? So the customization really comes down to the person.

And so it's really hard to give, like generalized do this. And it always drives me crazy when I see this online, this fix my elbow pain, do this every day before whatever fixture like. Who says that to the world? That's outrageous. 

Speaker 2: Yeah, totally. Tara, this is brilliant because I think many people listening can relate to the symptoms you described and to the type of program you helped us walk through.

If I can ask you a couple of things about different parts of your approach,starting with the symptoms, like you mentioned, yes, 80% of people coming to you find good results with this type of program. Uh, maybe one to clarify a question, so, so one is about the specific symptoms these people have.

we talked about, loss of range of motion, right? So like the in inability to to be able to raise their arm above certain height, and I'm guessing also [00:31:00] loss of. Effective strength at those different points in their arc of movement. when these people, climbers, when these people are experiencing these things, isn't just doing any kind of movement above that pain-free range, going to exacerbate that pain.

Particularly, because I, I love what you said. Like, Hey, let's get them, to the bouldering, wall at, at a more less aggressive angle. Because normally I would think that if you're on a vertical wall, a lot of your weight is on your feet, so your shoulder is less loaded the moment you move to.



Speaker 2: assistance wall, and bouldering wall, your shoulders having to just hold more weight. So wouldn't that normally cause more pain? And also bouldering typically involves more, uh, dynamic movement, which could be, you know, catching [00:32:00] and lunging for holes. I know that when I see other, other Middle East climbers, including myself, when we make those kind of movements on and in your shoulder, that sometimes leads to worsening of symptoms because you're having to, maybe you're introducing more load, maybe there are other things going on.

So I, I'm curious as to how this particular, protocol is, is effective or maybe I'm not understanding the entirety of the picture. 

Speaker: Yeah. Yeah. That's great. And I'm glad you said, uh. The protocol because what I just described would be like, let's say the first three, four weeks. But ultimately what I wanna make sure people understand is to say that reaching overhead and someone that has pain overhead is dangerous, is not true at all.

But it's really just a method that we can modify the primary activity that the athlete wants to get back to and give them some back so they can be satisfied while the symptoms settle down. Because we don't really understand where all the pain is coming from. And so when we give someone a, even with, [00:33:00] diagnoses by MRI, oh, you have a 50% rotator cuff tear.

if someone's saying that's where all their pain's coming from, that's fundamentally not true. We don't really know If their pain goes away, their strength comes back, their function comes back, we re-scan them, they still have a 50% tear years later, it's not gonna change. It'll probably get a little worse over time.

Right. And so we can't really say why they have pain, but it's just like one way that we can, try and help them build confidence by giving them stuff back that makes them, that they enjoy doing, while the body slowly does what it does best and makes things go away. When it comes to the bouldering wall, it's like definitely modifications.

So someone that climbs, like I talked to someone yesterday with shoulder pain that one of my primary questions is like, how, how hard are you bouldering? What's your grade climbing when you're not injured? That's a good benchmark, you know? And so it's like this person was like, I climbed V eight when I'm not injured.

Cool. So I know now as a climber. If they can climb V eight, you know when they're not hurt. Climbing V three and V four is really pretty easy for them. That's not that hard. So if I have them climb on steeper [00:34:00] terrain, 30 to 40 degrees, and they climb V three, they can do that pretty statically. They don't need to do big power moves, but putting load on the upper extremity is not a bad thing at all.

That's good. That's a rehabilitative thing that is rehab. And so the idea that if someone has a shoulder pain complaint and they need to go to a clinic and have someone evaluate all these things, because that's their problem is fundamentally not true. People would be just as well off to modify their primary activity to a satisfactory level at a lowered intensity and volume and just be patient as hell.

And that would make a lot of people's pain go away, right? Because every time you climb a wall, you're using your scapula. Every time you pull through a move, you're, you're drawing your scapula down and back. Like all of the, all of the motor control things we try to isolate with in a clinical setting, those happen all the time on the climbing wall.

It's, it's really just about the total tolerance of the body and the robustness of an individual shoulder. 

Speaker 2: that makes a lot of sense. You're right. I think being able to climb at a level that [00:35:00] doesn't aggravate the pain, because that's one kind of feedback we get as athletes, doesn't aggravate the pain.

And then also provide, that, like, let's say the, the mental health relief that people need because they're now able to go and do this activity they enjoy in the company of people that they like to be with. I think that gives people some, some much needed, Sanity relief that hey, they are still in the sport.

They are using their time the way they like to. I know that continuing to do that thing below a certain threshold is not really making, it's certainly not making the injury worse. And maybe it's helping or not, I can't say, but like, it's certainly not making it worse as long as it's done in this like controlled manner, as long as it's executed.

below that person's, uninjured capacity to perform. How important is it, Tyler, for somebody to regain full range of motion in that [00:36:00] shoulder? Is it also something that you keep a keen eye on before you allow them to resume, full execution of their sport? Like if somebody is still not able to, get their arm to a certain level, are you asking them to get that back before you have them increase the load?

Speaker: So the most, the most natural way of thinking about it is asking them, prior to this injury, like, did you feel like range of motion was a limiting factor for you? like I have terrible range of motion on my shoulders, and I know it's been like that my whole life, but because of that, I can, like when I was a kid, I could throw a baseball really fast.

I could throw a football really far because I played ball sports. So there's benefits to having a stiffer joint with a little bit less range of motion. But there's also downsides too, so it's not like. One is better than the other. They're just trade-offs. But people that have a big range of motion tend to have more injuries because they load the joint more.

So I always have someone like ask them like, is that something that's been normal for you in your life? yeah, it's been like this a lot, but now that it's way [00:37:00] worse 'cause it's sore and that, and even if they say, I have a really big range of motion, never bothered me, but now I can't really do it.

Both cases would essentially lead me to tell them, well, that'll go back to normal once the pain's gone. Because ultimately the guarding of the joint is driven by the brain being fearful about moving the joint. And so when athletes feel like they're gonna hurt themselves with a particular range of motion, they become habituated to not use that range of motion, that propagates a reduced range of motion.

But the literature would suggest that once people's pain goes down, their range of motion comes back just normal. And so putting too much of an emphasis on the range of motion too early. In my opinion doesn't make as much sense as doing just basic strength training things or motor control things that they enjoy doing.

'cause they'll get a little bit more out of that in terms of loading the tendons and loading the muscles and getting some coordination instead of doing a lot of passive range of motion. 

Speaker 2: Got it. Tela, it totally makes sense when somebody has this sudden injury, which [00:38:00] causes that, depletion in that, in the range of motion.

And then once you're beyond that, you can get that range of motion back. But what about athletes? Again, likely older athletes who haven't had a sudden point? It might have been just this. Gradual loss of range over the years. And it could be because they might have hurt something in their shoulder at some point that they didn't realize, and maybe those that injury now has turned arthritic and they've lost, they've lost like, cartilage and other things in that shoulder.

So they may not actually even know what normal range might be because that, uh, loss of range has been so prolonged. What would be your counsel and treatment for those athletes? 

Speaker: I mean, there, the evidence is, I, I would say relatively well, pretty strong that full range of motion strength training is the best option for optimizing an individual's range of motion.

So regarding the shoulder, it would be like [00:39:00] doing a dead hang from the bar. Where you're literally just hanging right below, loading the glenohumeral joint, loading the capsule, you know, loading the scapula, et cetera, and just doing a dead hang. Other ways that people would do it is like external rotation where you're like laying on a bench on your back and letting the, the weight pull your shoulder and external rotation, you know, doing movements like that, you don't want to do a lot of the, I mean the evidence on holding positions is largely neuromodulation, like your brain just gets comfortable with the stretch in that particular setting.

But long-term to make changes, we need to do just a strength conditioning program that is more comprehensive, that does full range of motion loading. And that's honestly the best thing they can do for what, for trying to optimize their normal range of motion. But their normal is not the same as your normal.

It's not the same as my normal. And that's where it gets messy with. The joints in general is they're not all built the same. And so if we, and we don't have good standards, especially for the scapula, it's like, it's kind of confusing for people, you know, to know exactly what's normal. But [00:40:00] the pain and the function matter way more than what the normal, you know, range of motion looks like.

Speaker 2: No, I think that makes a lot of sense. Everybody's bodies are different and what's normal for me, for you or somebody else, those could all be different. But maybe just trying to find a way to, uh, unify, maybe an example could be a climber trying to reach a hold above the head and that person may not able to reach it because the arm doesn't extend the whole way.

have you found that. Again, athletes who come to you who haven't had that ability to be able to, again, reach high up for a certain hole. Or maybe another example could be,uh, provoke their shoulders in like less natural, positions. It could be like a severe gastro or, or, or a severe lock off.

So have you found that athletes who have severe shoulder degeneration, because of arthritis and other things, have you found that those athletes are able to eventually complete executing those types of climbing [00:41:00] moves if they go through the right protocol, the right rehab, and give themself enough time and patience?

Speaker: Yeah, yeah, of course. Most, most people, I mean with the exception maybe of some like, 10 ESIS surgeries or when people get their labrum repaired, I think surgical interventions will potentially reduce range of motion long term, not hugely limit range of motion, but you know, the consequences of having more stiffness there, I think would manipulate someone's normal range of motion that they're used to.

but I think from like a tendon tear standpoint, from the more common rotator cuff related shoulder pain syndromes, I think most of those athletes will get back to normal positions that are stressful. Ultimately, getting back to the highest level, climbing for an individual is always really stressful on the body, especially the shoulders, because those positions are mechanically not very strong.

And so I think most people should, should expect to get back to a high level of function, but the tolerance of that. Exposure might be a little bit different, right? Because once you have a [00:42:00] rotator cuff tear, they don't really heal and go back to normal. Even with, you know, what we would consider sophisticated techniques like PRP injections, they're not really that helpful, you know, so people will have a bit lowered, maybe tolerance than they were used to when they were younger.

But that's a normal over time adaptation that athletes need to learn about managing how much they can tolerate in general anyways. Maybe that would be helpful for people is think about the, like a progression. So we're just talking about something that has pain reaching overhead, right through the painful arc.

The way that I think about it conceptually is if you think about like, uh, doing an inverted row, which is like a, you know, a bar in a squat rack and you're doing a horizontal pulling motion, but you're looking at the ceiling. That's the inverted part, right? We could start with just like horizontal polling movements, which are pretty stable and safe on the shoulder.

Lots of protection there. And then we could transition to them to using like a lap pull down machine where they're sitting, but they're leaning back. So now it's not straight horizontal. Now it's kind of at an angle, [00:43:00] right? And then you could progress them to doing pull-ups. So now they're going overhead.

So that's like a, not a weekly protocol, that's like a trajectory over a couple months. Right? The same thing would apply to the climbing wall. If they climb at 40 degrees, slow and controlled, they then progress to 30 degrees, then they progress to 20 degrees, then they progress to vertical. So it's like the progression in reaching overhead range of motion can happen naturally without.

Being overly intentional with having them do a bunch of overhead activity at the beginning. That might be provocative because we know that when their pain goes down, their range of motion will return. We can be strategic with how we organize someone's training and it'll get better, like without having to be overly worried about it.

Speaker 2: Beautiful. No, I think that makes, that makes a lot of sense. planning that person's pro program so that they graduate from doing different types of loading at different angles, and then eventually they can get back to maybe doing just normal pull-ups. Tell, are there any gold standards, any, like you, you [00:44:00] mentioned a couple of exercises that I thought I would ask you maybe for a couple more on what are known to be most effective and let's say most climbers cannot apply to everybody because everybody has different bodies, but like you talked about.

That hangs. And then you talked about, you know, rotators, Talked about like those exercises where you rotate your shoulder at a certain curve using maybe different, methods, maybe bands or dumb buts. Can you talk about like some of those which you have known to be in your experience to be the most effective 

Speaker: I would think for overhead athletes, the literature would say, if you wanted to like test someone's shoulder, the most gold standard testing is done like at 90 or of zero degrees of abduction. So that essentially the arm is at your side, maybe with like a towel between your torso and your arm measuring rotation outward.

So the palm going away from midline in a neutral position. So essentially doing a peak force test with something like the ec, you would attach it to [00:45:00] something and then you would try and rotate against it and get an isometric force readout. And then you would also attach it in the other direction going away from the body and then rotate down and in to measure internal rotation.

So you would get a ratio between external rotation and internal rotation, and then also doing that at 90 degrees external, going back internal going forward. And you can get force measures there and measure someone's side to side. That's probably the gold standard testing set up. and then in addition to the force, you could measure rate of force development and then you can rest measure consistent force or capacity in those positions.

those are things that people can set up pretty easily for themselves if they have a tin deck and. But people can get obsessed with those. 

Speaker 2: Assuming most people may not have a tin deck, what should they do? 

Speaker: if you don't have a tin deck, don't, don't worry about those numbers because you can use other devices and you can use a handheld dynamometer, but you need someone else to do it.

But just as like a gold standard testing thing. But those are similar positions that people would train. So like [00:46:00] training shoulder, external rotation from this position is largely effective for loading the posterior shoulder. you could do this standing if my arm was not resting on something, or I could rest it on like a table or a bench or a loading pin, and essentially would just rotate here with a cable machine or a dumbbell that would load the posterior cuff for the posterior deloid.

You know, do, like we talked about earlier, you could use lie on your side dumbbell, bring the dumbbell across your body. Bring it out behind you. Not load the posterior deloid, but all the motor control stuff like laying on your stomach, doing the i Ys and Ts, people are very familiar with those. Those are fine too.

Those are good initial loading strategies for people with shoulder pain. And I think those are okay to include just generally speaking for like just health in general for movement variability through the scapula. But they need to be progressed, right? Because as soon as you can do an exercise, 10 repetitions, three sets of 10, and you're not changing it, you're not really doing anything else, you know, you, you have to keep modifying it.

That's where the strength [00:47:00] trending movements come in. something like a face pole, right? You've probably seen face poles before. Those also will load the inferior and the middle traps. Right? So, but those are easier progress. 

Speaker 2: Tyler, this is, this is brilliant. Thank you for walking us through these, in this detail.

For those people who are listening, we will post a video of this on YouTube shortly, so you can actually, come to this session and, and watch Tyler demonstrating these exercises. So, so these are super helpful. One, maybe one other question on this is, what about, frequency of doing these exercises?

Should these be done? every day. Should we give you a couple times a week? Should these be done on the same days as, as climbing days versus doing these on like, resting days before the climbing day? When would you advise? 

Speaker: So people definitely don't need to do it every day, and that's a mistake in my opinion, and the everyday, multiple day times.

Protocols are now kind [00:48:00] of, not popular anymore. And we realize that like everything is a, everything you do to your shoulder has some mechanical value to it, right? And so if I'm given 10 exercises I need to do every day that has a mechanical load to it, that's kind of hard to quantify, right?

And so I always think about it from, and it varies person to person of course, but let's say a really painful shoulder of someone that's never had shoulder pain before. And there was like an acute moment where they felt their shoulder get hurt, right? No big pop. But they heard, they, they felt something and it's been really sore, like typical shoulder tip pain.

Thinking about it from like the safest to the most intentional is how I think about the training. So like I would, before, I probably wouldn't have them climb right away, but they could still do stuff at the gym. But I would start with the safest thing. So have them do like a farmer's carry. Or shoulder shrugs or a hex bar deadlift, something where the arms are just by their side, but they're putting load through the shoulder without actually doing a lot of movement to the shoulder.

So I would like warm [00:49:00] them up in that way. If they can tolerate horizontal pulling, I would have them do an inverted row isometric. So they would be like, their body would be inverted on a bar and their elbows would be at 90 degrees and they're just doing a holding position, another very stable, not threatening kind of movement.

Then I would have them do a couple sets of that, have them get on the floor and do some pushup isometrics where they're also holding the position not moving. Then do some block lifting from the floor, and then you can do all the the other things that we showed you. We could do these in isometrics. We could do cross body movements in isometrics.

But that's where I would start and I would give them those things to do as the preparatory stuff before climbing. If they're ready to climb and we feel comfortable getting them on the wall, we can do that right away. But if not, we'll just keep doing those for a couple weeks to build their confidence until they're ready.

Then we'll do the wall stuff that we're talking. If they're familiar with strength training and they like strength training, we would have them do a strength training day too, where they can do a lot of the same things. They could do horizontal rows, they could do partial range bench press. They [00:50:00] could do Arnold Press overhead if, because there's more rotation.

But there's all these things that they can do. So we just gotta figure out what that is. Just like everyone, like you make assumptions on what people can do. And so with some, if someone has like a, a more acute pain complaint, I usually give them stuff to do for two weeks and then we talk on the phone.

'cause if I say, here's this stuff for four weeks, I'll see you in a month. Lots of stuff can happen in four weeks. Right. They can be really fearful about a thing. They can have one bad day and kind of freak out. They can. Feel like they're doing way less than they should do. And so it, it always has to be very transparent that I have a pretty good idea of what we can do, but I don't really know exactly what we can do.

So I have to give you things, listen to the feedback, modify those things, and we just like now to, keep climbing, let's say pun intended together to get back to where you want to go. That's should be the general template for everything. But it's hard to do that in a clinical setting because a lot of people just like, especially PTs, they're overworked.

If they work in a big clinic, they see [00:51:00] three people at the same time and they just go through the same damn protocols. And the person standing there is like, why am I even here? I'm doing, I can do this on my own. Why am I coming to this office? 



Speaker 2: sure. that's sound wise. And every person's history is different and people have to.

Try something. When people pass something new, you kind of have to go back and evaluate how well that new therapy procedure is working and then change that because yeah, everybody's, everybody may react fully to different things, so getting frequent evaluations is probably really important.

Maybe this is a good point to ask you, Tyler, I know you work with over athletes, particularly climbers. If people need to work with you, how can they reach you? I know you keep a very busy schedule, but, uh, what is the best way to learn about the work that you do? 

Speaker: Yeah, I mean, I think the, I have a website obviously that has like a location for doing remote consulting or in-person consulting if [00:52:00] they're in Utah.

Um, my Instagram account is probably the most active thing that I use, which is at C four hp. I mostly worked with rock climbers, but I played baseball into college as a kid and played ball sports. And so in terms of managing shoulder and elbow and pain complaints more generally, I do a decent amount of that, um, just from people referring their friends and other family members that aren't rock climbers, of course.

So it's, it, I can definitely help in that regard too. but my, obviously my expertise or my real interest obviously is in rock climbing 'cause I do that myself. those are the most, the primary locations. And like on the website, there's lots of podcast things that I've done with you and others too.

If people wanna learn more about what I'm interested in. 

Speaker 2: Yes. I think most people in the world of climbing now are aware of the services that you provide and you provide so much helpful information through your Instagram account amongst other channels. So yes, we will put links , to those on the show notes if people don't have those bookmark already.

Before we go, is there anything that we missed, Tyler, that you want [00:53:00] to speak to or, or not? 

Speaker: Uh, maybe one thing that I thought of, when you were chatting was the expectation is really predictive of the outcome in the shoulder with pain complaints. And so if, this is kind of a, one of the hard things with that healthcare providers have PTs and chiros and people that do rehab, is if someone comes into their clinic and they don't really understand or think that rehab is gonna help them, their outcomes aren't as good.

If someone comes in. So I'm, I'm very fortunate and my demographic is, my demographic is very compliant. Like my athletes are climbers. They are very physically active, they're very healthy, they're usually, very affluent. Like it's, that's a very easy demographic to get better because they're, you know, they expect to get better.

And so that also is something that kind of is troubling with managing pain complaints where some people feel like, I, I don't, I, I have this tear. I feel like surgery's the only thing I can do. Those people are harder to get better with [00:54:00] rehabilitation too. And so it's like, it's really confusing. And so one of the most important things for maybe healthcare providers or even patients is if the person that you're talking to isn't really trying to understand like what your real intention is or what you understand, like the outcome is a little bit more.

Unpredictable. Right? And so listening to the patient is so important to send them in the direction, right? It's not my job to tell people what to do. It's my job to inform people about all the potential options they have and the predictable outcomes as best we know. And then let them make the choice as to what's the best, you know, what, what makes the most sense to them, but not like, oh, you have to do this.

This is gonna fix it. Because we just don't know. That just is not information we have. 

Speaker 2: You are absolutely right. Climbers are usually very motivated, and if you tell people that they need to go and uh, do these exercises and follow this program, I think you probably have to stop them from doing more than is asked for.

Doing too much. 

Speaker: Yeah. Yeah. I joke with people when I teach courses, like, your job as a [00:55:00] healthcare provider for climbers is to educate people on doing less just period, right? Yeah. Like, 'cause I could give someone the most. Complicated evaluation in the most objectively significant thing. And it doesn't matter if they're just doing too much still, it's just is a waste of mine and their time, unless they're really educated on recovering better.

Speaker 2: One thing, uh, that came to mind about, uh, maybe more aggressive interventions maybe you know more than, more than the rest of us do, there might be cases that come to you where yes, maybe they have explored or exhausted all avenues. They've done all the PT and the shoulder isn't getting better. So have you learned of any new interventions surgically?

We talked about PRP for a second, are there other things that have come to life with like biologics or orthopedics that you found are now making, making a dent? 

Speaker: No, those are still largely exploratory. Like [00:56:00] people that get like, um, grafts for the tendon, like the tendon grafts for big tendon tears, they, their incidence of re-rupture is really high.

Mm. Or like if you, and same thing with PRP, like in the, it might be a short term effect maybe from placebo and it costs, it's very expensive, et cetera, but the outcomes are not better at all than just rehabilitation in three months timeframe. So it's like, if I gave someone the choice, you want to drop $800 and get a painful injection where you'll be the same as you would if you didn't get one in three months.

And most people will be like, hell no, I, I'll just wait. I can be patient and load and find things that I can do. And so even with surgical intervention, just basic surgical interventions, those aren't, there absolutely is times when those make sense for people when they have dislocations and some bank heart lesions and certain types of label tears.

And I'm definitely not antis surgery, but for. The typical shoulder pain complaint in a climber surgery is, is not usually a very reasonable option. 

Speaker 2: think this is the message that people need to hear. Like, yeah. When it comes to [00:57:00] shoulders, there really aren't too many shortcuts available. You kind of have to go in and be patient and do the work.

I actually received a PRP and I had my, my outcomes are actually worse than, like nothing changed. I just went through the worst pain episode. So if anybody comes to me now and says, Hey, listen for me, do not go get a, get a PRP for your shoulder because it might actually set you back more than you, uh, you wanted.

Della, it's been amazing having you back on the show again. Thank you so much for helping us understand what's going on with. Our shoulders and how we can keep our shoulders moving strong and listen to things when we have to listen to things and follow the right things at the right times to keep climbing and, and keep surfing.

And keep swimming for as long as you can. 

Speaker: Yeah. Great. Thanks for having me. It's always fun to chat. Good to see you. 

Speaker 2: Yeah. Thank you for all the amazing work you do.