Question
QUESTION: Hello Doctor,

Quick background/history:-
Age: 30 Years
Bodytype: Athletic/ Ecto-mesomorph
Profession: IT consulting
Activities: Weight training 5 days a week, have been into bodybuilding 10 years back. Left it for last 9 years.
Preparing since 2010 for making a comback in the state level bodybuilding contest scheduled to be held in 2012.

Problem:-
I've been experiencing some pain at the tip of my left shoulder since 6 months now. It did not start with any accident or shock while doing workout as I've been always keeping my repetitions deliberate and controlled.

I consulted some doctors and received guidance and exercises for shoulder stability and stretching.

The X-Ray clearly shows Type-II separation of AC joint. Pain is felt on the tip of AC joint, but rarely, typically after heavy chest day. Also, whole thoracic cage seems to be torsioned on one side.  

I've consulted a chiropractor as well. Received a good soft tissue massage that initially got rid of lot of stiffness in some of the rotatory cuff muscles. It gave me confidence to go back to gym and workout again.

Recently consulted gym's physio and and have been suggested to use rigid kinesiological tape while working out. This has definitely added some support to loose shoulder joint. However, the bulge seems to be getting bigger after every episode of post workout pain. This typically happens on heavy days as mentioned earlier.

It happened again yesterday when I reintroduced upright rows with barbell after a gap of 6 months. In general, I've been doing uprights with dumbbells instead and had no pain with them.
I thought I'm stronger, but I could not understand what went wrong with my scapular movement and I started feeling pain right in the gym - for the first time. I stopped there and chose to take RICE.

The question:-
Symmetry being very important to be in top guys in the contest, I want to get strong. Also, willing to get my thoracic imbalance corrected and shoulder stabilized. Is it possible that my left AC joint will return to normal by just exercising?

Please advise.

ANSWER: Hi Amol,

First, stop doing upright rows with a bar.   It puts undue strain on the shoulder by placing the shoulder in an impinging position during the lift.  Also, there were a few things that were not clear.   You mention AC joint separation, and these are graded as "Grade 1, 2, or 3," with 3 being a total dislocation, and 2 being a partial displacement (superiorly) of the end of the clavical against the acromion process of the scapula (both of these parts, acromion and clavical form the acromio-clavicular, or AC joint).  Then you mention a bulge.   I am assuming you mean the elevated clavical bone at the AC joint is prominent.  Correct me if I am wrong.  However, acromions are evaluated on x-ray to be sloped downward as a "Type 1, 2, or 3" and not a "Grade 1-3."  There is a big difference between a partially dislocated AC that is "graded" and an alteration to the architecture of the acromion in the shoulder that is deemed a "type."    Also, I am not exactly sure what you mean by thoracic imbalance.   A strength imbalance?  A boney asymmetry imbalance to the thoracic cage (e.g. spine/chest/ribs)?    Here are my thoughts:  If you irritate the AC joint it will become swollen and stick up more.  Though you did not have an acute trauma, you may be irritating it by some of the weight training, e.g. upright rows.  You may also have a downward sloping acromion, a "type-2."  This can cause shoulder pain by impinging one of the rotator cuff tendons, but this pain will not equate to any visible asymmetry.  Regardless of whether it is a Type-2 Acromion architecture or a Grade-2 dislocation, exercising will not change either of these.  So long as you do not have pain, you should be able to gain strength.   If your visible "tortion" is to the spine, e.g. scoliosis, then that is not something that will go away with exercise or anything else.  I would need to know more about what you mean by tortion.   

Dr. G'
www.drgillman.com


---------- FOLLOW-UP ----------


AC Joint XRay   QUESTION: First, I'd like to express my gratitude for your response. Attaching an X-Ray for your reference. Also answers to the questions that you asked.

What I meant by thoracic imbalance/ tortion is mainly a boney asymmetry of the thoracic cage. I am not sure why it is so but my right side of thoracic girdle looks  smaller as compared to left side. Left shoulder is elevated than right. Also, interestingly, I recently observed that the origin of posterior fiber of sternomastoid on left is closer to jugular notch - almost the half way - as compared to right.
Little more on asymmetry, a white line is observed running from bellybutton to chest. This line is not dividing my torso into two identical halves. It has sharply bent towards my right clavicle significantly in upper half of sternum.

One more symptom that I missed: I can hear grinding sound in this soulder, especially when I'm lying supine with humerous perpendicular to torso and move forearm in an arc. No pain associated with this.


About the bulge, you are absolutely right here too. I can feel the elevated clavicle bone at the AC joint and is quite prominent. No pain at the moment but
this question keeps coming in my mind. I may gain some strength back but will my AC joint become visually normal ever again?


It is definitely a great relief to hear that I can continue to do workouts and gain strength as I have no pain. I've stopped using barbell for uprights. I would like to have your advice on exercises to be completely eliminated from my schedules. Especially, what is your opinion on heavy squats, deadlifts and cleans. I would like to include them during my strength mesocycle. Please advise.

Thanks.

ANSWER: Amol,

First, your x-ray looks okay.  No worries.  I would guess at this point that you simply have asymmetry that you were born with and developed.   I don't know why your SCM muscle would be asymmetric.   I am not a fan of heavy squats for the general population.  It's not a great exercise as it can hurt you.   If you are training to be a powerlifter or olympic lifter, than okay go ahead.   If not, then you do not want to go heavy.   Deads and cleans are okay.  Also, try split squats.   As for your shoulder noise, this is common after a shoulder has been strained or injured in some way, and it also is common with mild arthritic conditions.  Even mild shoulder AC joint sprain or repetitive strains can cause the joint to become noisy, with the popping crackling called "crepitus."    Just for your own rehab, and to keep good balance in your shoulder cuff, add the shoulder "W" exercise (see: http://www.youtube.com/watch?v=_G0feLqXA0E).   

'Best of luck with this.

Dr. G

---------- FOLLOW-UP ----------

QUESTION: Hi Doctor,

I've been doing the shoulder "W" exercise thrice a week.

However, recently, I've been getting similar pain again. Typically, after 2-3 hours of my bench pressing activity, I start getting some pain in my left AC joint and occasional pain in right AC joint too.

Just to add more clarity to the situation, here's what I'm doing right now.

I've been continuing to do my workouts with the following precautions:
1. I do my worm-ups correctly.
2. Ditched barbell uprights completely also eliminated heavy Squats
2. Bench press/ any chest exercise with correct form
3. I've been following shoulder rehab program from here: http://tiny.cc/acrehab
4. I've been doing a flexibility exercise http://www.crossfit.com/mt-archive2/matt_mast_shoulder_roll.jpg this for over 2 weeks now. Initially it felt better and I could narrow down on grip every time. But the visually popped out clavicular distal head is still the same.

5. For supporting skeletal system, supplementing it with Glucosamine, Chondrotin and MSM at night and calcium at morning. For last 30 days.


Doctor,

I'm preparing for a local naturals event scheduled in late 2012 and getting doubts about my cortisol levels.

I'm gaining significant strength with all rows and pulling movements, deadlifts, all leg movements BUT not gaining good with my chest and shoulders movements.

I'm worried that this occasional (once a week) 2-3 days lasting pain may be shooting my cortisol levels up and affecting my overall progress adversely.


Please advise.

Answer
Amol,

The crossfit shoulder exercise can strain your shoulder if you do it too far or too often.  You need to consider scapular stability training.  Your cortisol will not be affeced by your shoulder.  If you are weight training with an AC joint that has been injured or is problematic, it will remain problematic to some degree.  You really need to have a sports chiropractor or some other musculoskeletal specialist examine you to determine where you have problems.  \

Dr. G'