Shoulder Problems

shotWith increasing pain in my right shoulder, mostly when hitting topspin forehands (my favorite stroke!), I went to Naples’ orthopedic Dr. Havig yesterday and got a “cortisone” shot that will hopefully take care of the problem.

Bicep Tendonitis

The pain is identical to what I experienced eight years ago (which resulted in my only miss of John Newcombe’s October Fantasy Tennis Camp for 13 years). That time was the result of my jumping on the Luxilon Big Banger hard string band wagon.

In taking my history yesterday, the very nice lady Physician’s Assistant asked “what changed to cause this pain?” My Volkl racquets are the same. The Gamma Moto/Glide strings are the same. The string tension is the same. Playing six days a week is the same.

What Changed?

My analysis is that I fell in love with hitting my forehand HARD and have been really attempting to crush the ball (like the big Boys) past my opponents. So will I learn a lesson? We shall see when I get back on the court after four days of letting the shot take effect.

Has anyone had a similar experience?

You should only have 3 injections?

According to Orthosports.com “There is no scientific evidence to support this statement, but it seems to have been set in concrete somewhere along the line. Common sense would suggest if 3 injections given at 4-6 week intervals have been unhelpful then further injections are less likely to be beneficial, but having one further injection if progress is being made is not inappropriate, or indeed dangerous.”

Small World

The tennis world is small… Dr. Havig mentioned that he took his high school daughter to view Dartmouth over the winter and took a picture of “Chuck Kinyon’s Wall of Honor” to send back down to Naples to his best friend and fellow doctor who played tennis for Chuck for four years when he was at Dartmouth.

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12 thoughts on “Shoulder Problems

  1. I had a full shoulder replacement last May and have had a wonderful recovery. listen to the DR when it comes to the waiting periods for cortisone, if you rush back it will lose the effectiveness. Be patient. I had 2 sets of cortisone shots for spinal stenosis and claudication and the waiting period and therapy were the keys to me not needing back surgery—BE Patient. Stop playing 6 days per week you are not letting the fluids in the should time to recover — the tendons, muscle and cartilage need recovery after stress,
    Every time you hit topspin you compact the shoulder orbit and stress the joint.

    Bill, good advice. thanks, george

  2. George from my experience the cortisone only masked the injury and makes you think it has gone
    Beware because it hasn’t and you can injure yourself more

    Gail, i think it is the same with the anti-inflammatory drugs: they do reduce inflammation; but also mask the pain. thanks, george

  3. Comment offline from a friend:
    George, Sorry to hear about your shoulder. I would suggest, from personal observation of my girlfriends experience, that the cause of the shoulder problem is from the sudden STOPPING of the forehand swing. Best of luck with the cortisone.

  4. 1. I supposed like all of us, when you hit your forehand you’re mentally seeing a picture of Roger Federer’s forehand and assuming your motion is just like his. This may or may not be true and but a professional might be able to assess this more objectively.

    2. A professional might also be able to help with other suggestions regarding racquets, sting tensions, and other aspects that might affect your shoulder.

    When I suffered from shoulder impingement a couple of years ago, I got a lot of good help and advice from Joe Bartos. He changed my service motion (temporarily) and helped me with strings. A couple of workouts with Joe might be helpful. If not, he’ll tell you and at least he’s on your side. I’m sure he’s got plenty of experience in dealing with people who have shoulder injuries but want to keep playing. He’s by far the best pro I’ve ever taken lessons from.

    Scott – good advice. The strings i have been using for more than a year now came from Joe. thanks, george

  5. George, we have spoken about this directly, but it’s important enough to discuss it further. The injection of steroids can help, temporarily, when the cause of the pain is inflammation. The steroids reduce inflammation which enables the body to repair itself. However, if there is a tear in a tendon, the steroids can aggravate the problem by preventing the formation of scar tissue.
    The only way to truly determine if there is a tear is with an MRI. The only remedy for a tear is surgery. Physical therapy, and appropriate exercises are essential after surgery to regain strength and mobility.
    Nine years ago I had rotator cuff surgery for three tendon tears and destruction of all the joint cartilage. I was advised by my orthopedist never to play tennis right handed again or I would need a shoulder replacement within a year. I played left handed for 1 1/2 years, but through strength building and mobility improving exercises I was gradually able to get back into playing right handed again.
    If the beneficial effects of your steroid injection wear off fairly rapidly, I would definitely recommend an MRI.

    Thanks, Doctor. That is why you can switch hands and hit lefty! george

  6. George, I’m at the Atlanta senior invitational. Today I played Evert Jonsson whom I had lost to in a close match in Naples. I was using a new ASICS with a smaller grip and looser strings than I had played with yesterday and didn’t have much competition so it felt pretty good and I liked the extra power I got from the looser strings.

    I won the first set today 6-4 and then started to get tight as Evert played better and missed less; and my forehand started to fly and then I couldn’t follow through. It was a combination of the smaller grip and the looser strings. So I switched to my older Asics, same frame, but I had recently re-strong and strung quite a bit tighter with all Polly. The newer one was half poly and half synthetic gut. The one that I had just restrung had a significantly larger grip and gave me better control.

    The tighter strings forced me to follow through with the complete stroke and I ended up winning the third set 6-4.

    My shoulder doesn’t seem to hurt at all anymore in serving which is peculiar; because I had done nothing but play with the sore shoulder. But serves and overheads are much stronger now since my shoulder pain has gone away for no apparent reason.

    Tomorrow I play Hugh Thomson in the semis. Dick Johnson had a three set win over Rashid 4-6, 6-0, 6-0; and Don Long beat Bob Stock four and four. Don and I play Thomson and Jerry Thomas in the semis tomorrow and Dick Johnson and Evert Jonsson play Jimmy Parker and Jody Rush in the other semi.

    Fred, thanks for the update. The link to the tournament is HERE george

  7. I use stiff strings and hit heavy top spin most of the time. I believe the secret to preventing these injuries is resistance training with short single sets using the heaviest weight you can slowly continuously move to full muscle exhaustion. The other key is an adequate recovery period after the lift which is a week for us ⅞older guys. Light weight, rubberband, multiple set workouts just don’t give you the strengthening of the muscles, tendons and ligaments that heavy lifting does but it can breakdown the fibers and if you do it too often can lead to injury.

    The muscles, tendons and ligaments are all made of thousands of tiny strands. The kind of injury George has means that he tore some of these strands which sets off the bodies inflammatory system. These kind of injuries are easy to diagnose. When the affected limb is held immobile for a prolonged period like sleeping or watching a movie it “stiffens up”. When you first go to move it it feels like someone is “stabbing you with a knife”. Then as you move around it “loosens up” and you just have a nagging “pinching” sensation. The symptoms fade over time.

    The cortisone the doctor will inject is a catabolic steroid that works by turning off the body’s inflammatory monitoring system. “Catabolic” means it causes muscle, tendon and cartilage breakdown as opposed to anabolic steroids used by body builders that cause the opposite effect. That’s why they can’t be given too often. If it were my shoulder I would dodge the needle, rest my shoulder for a week then begin a strengthening program like the one described by Doug McGuff MD in his book “Body by Science” where he cites and discusses the 100s of scientific studies that support this position. It has certainly kept me injury free for the 2 years I have been following his program and I have more than doubled my strength on all exercise. And the cherry is that its 45 minutes once a week. Oh and I am a retired Family Medicine Physician.

    Paul, great explanation. I do use the lighter weights and bands three times a week; but will check out Dr. McGuff’s book. thanks, george

  8. Body by science has been around for a while now and dr McGuff who’s been an ER physician for a long time is the real deal….

    I know you don’t want to hear but rest/break might be in order 🙂

    Question for Dr Fenster, if it IS perhaps a really tiny tiny tear… Does the body have the ability to heal those tiny tears with rest…..vs surgery?
    I know soft tissue injuries can take 3 months to fully heal sometimes more…is this similar?
    Thank you

  9. Marc, that is an excellent question.
    If the tear is small, the body can repair it with scar tissue. When the tear is in a tendon, or a ligament, repair can take many months because of the poor blood supply to these tissues. Needless to say, the affected part must be rested during this healing period.
    For larger tears, surgery is the only option.
    None of us wants to give up our sports activities, but sometimes the body dictates what is necessary. George referred to this in a previous column – listen to your body, or in legal terms “res ipsa loquitur” (the thing speaks for itself).

  10. George, As you might guess, I had to chime in on this question. After thirty years in professional baseball and 50 years as an athletic trainer, I have seen many shoulder injuries and issues, both acute and chronic. First of all, inflammation is actually a bi-product injury, which usually are tears – either micro and mango! As stated previously, micro-tears will repair themselves with adhesions and scare tissue. Major tears often require surgery especially if they are full-tissue tears and/or you do want to compete at a high level (I would place you as high level). So where does that leave you?

    1) Rest is definitely indicated – cortisone injection take 3-4 days to be totally effective if they are. I would avoid any more but definitely no more then 3 in a 12-month period. So PRESCRIBED rest is needed. By PRESCRIBED I mean starting a specific exercise program without causing irritation.
    2) After years of research and discussion, the sports medicine community have concluded that throwing shoulder (and elbow) injuries are a direct cause of scapular dyskinesis (altered scapular position/movement-Kibler) and weakness. Proper movement and strength is the key to functional shoulder movement and injury prevention.
    3) After rest, the program should mainly consist of postural exercises. That would include scapular elevation (shoulder shrugs), scapular retraction (pinching) and humeral rotation. The strengthening included seated push-ups, wall push outs, and the six-back program completed in a prone position (link – https://www.youtube.com/watch?v=iVz8KfuG0c4).
    4) I would not do the throwing motion (i.e. hitting a tennis ball) until I had no pain on those exercises. Now, that might only take 5-7 days depending the degree of “tear” you have. So I would not be too discouraged but I definitely would not try to “push through” the pain.
    5) The other exercises you do are fine but are what we would call “core” exercises that support the other exercises.
    I am impressed with the the other comments. I hope this adds to the discussion.

    Larry, your professional input is always valuable and always welcome! thanks, george

  11. Thank you Dr. Fenster!! And Mr. Starr’s comment really hit it home for me also.
    As to not wanting to give up our “sports -activities” , it’s simply a temporary switch to another enjoyable activity in my opinion. I’ve often been forced into a “rest and recovery” and always switch to something I’m not good at. Swimming is for sure one of my go- to’s.
    It’s “challenging and interesting” for your whole being (mind-body, being one anyway)

    @ Larry Starr, So reality is that MOST of these types of injuries are really micro tears from repetitive strain motions, plus additional localized strengths or weaknesses causing an imbalance in the overall functionality?

    Thank you.

  12. Marc,

    So many “it is” are really micro tears – i.e. tennis elbow, achilles tendinitis, patella tendinitis, etc. Actually, inflammation is a normal and needed reaction for healing to occur. That is the main reason that anti-inflammatories are often not effective and when they are seemingly effective it may be only because of pain relief. As an athletic trainer, we would always look at the total athlete. Therefore, anterior shoulder pain would be approached by examining posterior weakness, core weakness, postural weaknesses, and even lower extremity weakness/flexibility. I wished there was one easy answer or program but it is usually more complicated then that.

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