Study suggests surgery alternative for rotator cuff pain: push-ups, pull-ups | Hacker News Reader

Study suggests surgery alternative for rotator cuff pain: push-ups, pull-ups

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118 pointsHillaryBriss61 comments

This is anecdotal and people should be extremely cautious if they have RC injuries. Talk to a pro, look into proper exercise progressions, and start with baby steps even if you feel strong enough not to. But:

My right shoulder was a piece of trash for over 5 years. I couldn't use my trackpad or mouse some days at work because it became incredibly hot and excruciating. I couldn't throw rocks at the beach, ride my bike as far as I wanted, drive in comfort, you name it. Just standing could be incredibly painful if my shoulder needed rest. You don't know how awesome shoulders are until they stop working.

One day I decided to try the exercise route after avoiding it for a very long time. I did because someone shared an anecdote of exercise helping on reddit. I started a pull up progression using elastic straps to assist at first. I did push ups from my knees. I started doing stretches in door ways and on a big inflatable ball. I rolled myself on a lacrosse ball like the cross fitters do. If it fixes them it'll fix anything, right?

Within a year I was 'cured'. I was doing pull ups with a 45lb plate strapped to my body and push ups with the same plate resting on my back. I began weight lifting fairly seriously and made it up to a 400lb deadlift by the second year. My shoulder was a limiter in my first year, but once I took up yoga as well it never bothered me again.

Now, having said that, this all took a lot of time, energy, and will power. It's not easy and it's not a silver bullet. Your body will strengthen though and you can overcome biomechanical issues by working the system carefully, methodically, consistently, and with good sleep and nutrition.

But again, don't jump into it and don't expect it to be easy. My experience was positive in the end, but it's a total dog along the way. If you have the money, find a trainer who understands injuries and recovery. Get on a program and commit. The best thing you can do for your body is use it. But never go too hard, and go as slow as you can handle at first. You can make it so much worse in one little moment of overdoing it.

Hopefully someone is motivated by my anecdote because someone sharing theirs on reddit ten years ago really did change my life.

I would say pull-ups are far more dangerous than push-ups, on the shoulders if you do wide-grip, on the wrists if you do close-grip.

a lot of folks push their elbows out too wide on push ups. Ideally, they are in closer to the body, around 45 degrees out at the most. For many, especially folks newer to pushups, it is something they struggle with.

Because for many people the front delts are more developed than their chest and biceps so they are essentially doing a shoulder press.

You can also see it at the gym with people not doing a chest press correctly.

This pretty much mirrors my experience exactly, FWIW.

I am a big believer in this, so far doing a form of trigger point therapy on myself and exercise/stretching has relieved all my nagging pains (right shoulder, right knee, both wrists).

It seems completely insane to me that you would have a painful wrist or knee and start a regiment of ibuprofen for it. Why would you suppress your bodies signals that something is wrong rather than trying to get your muscles, bones and tendons to work correctly and healthily together. It's like fixing your car by turning off the check engine light.

> Why would you suppress your bodies signals that something is wrong

Because after so many years of living you realise your body is utter shit at sending the right signals.

Given the choice of "live with it" and having a wide and increasing array of palliatives to make living with it easier, or "suffer more exercise" that has at least a sunk time cost and isn't necessarily going to resolve the issue or reduce need of palliatives, is it that insane why someone would do the first?

I'm not anti-exercise (barbell squats are the only good thing for my knee that got out of whack from an elliptical) and think "so what's your plan?" when I hear excuses about weak X stopping people from even starting a progression system, but I don't think it's insane to make the tradeoff in favor of "living with it" and I've made that tradeoff myself at various points in life for various things besides body aches.

As an example, I would assume meds would start working noticably within hours whereas exercise is more of a long term thing.

However I am extremely interested in where you got your exercises from as my wrists have started to hurt and I want them to stop.

The internet is crazy full of resources for carpal tunnel relief. I just kept trying stuff until i found what worked.

My problem was a ton of tension/tightness in my forearm muscles that was leading to inflammation in the wrist making using mouse/keyboard pretty unbearable, even for browsing the internet. If you do some basic forearm/wrist stretching while probing the muscles for pain/tight feeling you will be able to tell if something is wrong.

I fixed it by doing a combination of stretching, rubbing really hard on the muscles, and pushing into the muscle while activating it. I would finish by holding my wrists in ice water. The whole routine took 10-15 minutes and after doing it for a weekish I was playing FPS games pain free.

Yeah I had some shoulder issues as well a few years back. An occupational therapist friend of mine was adamant that I avoid activities like pull-ups and hanging from a bar to try and treat the pain even though I'd seen evidence suggesting it was a viable route.

I ignored it since I wasn't convinced with her logic. Fast forward to now and I'm like you. I regularly rep 45-70lb weighted pull-ups and have gone as high as 90-100lbs. My shoulders have never felt better.

IDK. I broke my shoulder a while back and once it healed I had lost some strength and flexibility in my rotator cuff. I did a little PT which did nothing for me. Eventually I just decided to hit the gym and start building up some muscle. I've been doing dumbbell bench press and one-arm rows and have been very slowly increasing the weight, but the bad shoulder is still noticeably weaker. I always quit my sets when that shoulder starts to wobble.

You need a resistance band and low weights, not dumbell bench presses and one-arm rows to strengthen your broken shoulder. Speak with another PT

Rehab is now the best practice for a lot of injuries that would have been rest and/or surgery before. A large part of this is due to the recognition now that certain injuries, particularly tendons, require exercise to heal properly.

Particularly in the area of tendons; much rehab is now centered around eccentric exercises to load the tendon and encourage healing. Shoulders, elbows, knees, ankles, and etc.

Avoiding all pain is also pretty much out the window now. Rehab will typically start as soon as acute injury symptoms have dissipated and pain is not avoided during rehab; just moderated.

For anyone who wants to dig into this more lookup "tendinosis" and also eccentric exercises for [insert knee, elbow, etc injury here]. There will be medical studies you can read about the effectiveness.

In comparison, my injury doesn't sound as severe as yours, which was over a decade ago and it took over a year of trying almost all manner of physio, acupuncture, massages, sleeping on hard floor and other therapies, before serendipitously stumbling upon the lateral abductor/adductor rotator cuff exercises, as illustrated in the linked YouTube video. I used the cable machines with differing weight sizes, alternating it with resistance bands where possible and it took around 3-4 months to recover fully.

I have co-incidentally managed to screw it up again last week, by being overzealous in the gym, and it is entirely my fault for getting carried away! Although, all the symptoms are the same as last time, but I am hoping that it is only an inflammation. It will be unthinkable to do any kind of push-ups/pull-ups, planks, burpees, rows, TRX or any kind of exercise which agitates the injury further; I am inclined to follow the tried and tested method first.

https://www.youtube.com/watch?v=C3BOzN00kyM

> But again, don't jump into it and don't expect it to be easy. My experience was positive in the end, but it's a total dog along the way. If you have the money, find a trainer who understands injuries and recovery.

So I will agree mostly. I am at the age where I find I must ramp up exercise very slowly. If I do, the benefits are huge. If I go to fast, I pay.

I tend to be an off-and-on exerciser. When my back starts twinging, it is $DIETY's sign that I have not been doing my crunches....

But I think finding a trainer that understands therapy/recovery and that things need to go slow is..... let me say "difficult". Most are a little to exuberant and just don't have the patience (or respect) for a slow work-up. I'll save my money, thanks.

Actually, I have found that myofascial therapy from a knowledgeable provider has helped every single one of my long-standing pains of various sorts. Years of shoulder pain eradicated in two 1-hour sessions. A case of "trackball thumb" that made me switch to different pointing devices for 6 months cured in 10 minutes, and I was even taught how to work that one out for myself.

> But I think finding a trainer that understands therapy/recovery and that things need to go slow is..... let me say "difficult".

You're totally right, and I think finding that certain someone actually requires a lot of specialized knowledge to know what you're getting into. Failing that, very good references from people with past injuries. There are a lot of people out there who'll tell you they're professionals, but have never opened up a kinesiology text book or worked through a significant injury themselves.

Hopefully having someone at all would be better than going it alone, if only for the external motivation... But going slow is paramount, and if they want to make your recovery happen fast, it should probably be a deal breaker. That's a tough one.

Any particular recommendations for myofascial therapists in the bay area?

Myofascial Therapy Center on Hamilton in Campbell has a lot of great therapists. I also know a great therapist in Fremont if that is more convenient but I’d have to look up the contact info.

Thank you so much for your reply! I really appreciate it.

>My right shoulder was a piece of trash for over 5 years

I too faced this issue, moving my mouse to my left hand completely stopped the pain. Though it does return if I move the mouse to right hand usage.

Physical therapy is evidence-based health practice. This is sort of a "no shit" piece. Doctors want to operate on you - it's what they are trained for, it's how the make money. Hospitals make money off of surgery. Yet physical therapy gets better results.

Lookup washout studies vs knee surgery with results like this [1].

1. https://www.scientificamerican.com/article/study-suggests-co...

Absolutely. IMO for a lot of injuries surgery should be the last option. Anyone taking rehab not seriously should be well warned of the consequences.

The doctors I've spoken to in Australia all considered surgery a last resort when I asked why they didn't mention it for this sort of thing. They will happily admit the risks outweigh the benefit until all other options are exhausted. Having universal health care would have a lot to do with that.

I've seen a whole lot of people go through rehab who just don't want to do the work or see that time is necessary. It's really sad how they just don't allocate time for their healing.

At face value, full-thickness tears are different. Maybe you don’t need whatever muscle you broke in half, but that seems surprising.

After reading the article I’m not sure what the outcomes actually are. Did the shoulder compensate and just let that muscle atrophy? Did it reattach? Either way this is definitely not a no-brainer.

Yes. I'm not sure this is so true for full thickness tears, but in general I think your point stands.

That said, patients also want surgery. I can't tell you how many patients I have referred to physical therapy for conditions which we know are improved by physical therapy (like routine lower back pain, minor muscle strains, etc) and they look at me like I'm crazy. I've seen it work in my patients that actually went and participated, but most go through the motions and stop going after a session or two because 'it wasn't helping'. I think part of american culture is that we want instant fixes, even for problems that have been brewing for decades like heart disease and diabetes... /endRant

People want a magic pill to be healthy, pretty, famous and rich. It’s human nature, we want everything right now.

It's interesting how relative it is too. For people who like to be active some of these new rehab programs and findings are essentially "magic pills". "Wait, you mean all I have to do is just 15 minutes of exercises only once every day and my knee/wrist/elbow/shoulder might be 100% in 6 months?! Amazing!"

How do I find your practice IRL? It’s hard to find people that don’t just recommend surgery because the system wants them to.

sorry for delayed response. I'm a hospitalist, so don't have an outpatient practice...

Yeah, I'm guilty of thinking this way as a patient. I had bursitis issues, but I convinced myself that it was a rotator cuff tear, partly because I didn't know that the bursa were a thing. I was skeptical of PT, but that along with anti inflammatories pretty much made me good as new. I was down to 170 just from avoiding upper body due to excruciating pain, but after PT I am now stronger than before and back up to 195ish.

> Doctors want to operate on you - it's what they are trained for, it's how the make money.

Is that it, or is it more if you are a hammer everything looks like a nail. A surgeon only knows how to fix things by operating on them. They are going to suggest that.

Besides that proper face pulls, ideally a resistive band YTWL[1] (another alternative is to do body weight YTWL by lying down [2]) exercise as well as walking with your thumbs forced straight to the front (if your thumbs point towards your hips when your hands are loose you have improper rotator position in your shoulder) helps wonders with any shoulder issues.

[1] https://www.youtube.com/watch?v=ELe4fATl-Jg [2] https://www.youtube.com/watch?v=3MxHX9j15BU

Another very good exercise is to stand straight against a wall keeping your shoulder blades, mid back, butt, elbows and wrists touching the wall and doing a shoulder press motion. The motion should be done without the elbows and the wrists coming off the wall, even people in tip top shape find this exercise extremely difficult to perform and most people would top out at just under a 90 degree bend in their elbow at first.

Unless there is actual damage to the joint (e.g. scar tissue that gets inflamed and must be removed) surgery should be avoided at all costs, nearly all orthopedics conditions can be resolved by strengthening under developed muscles that would make the joints work as they should.

Shoulder issues tend to happen due to weak back/rear delts and overdeveloped front delts and chest muscles this is the bane of the modern slouching life style.

"helps wonders with any shoulder issues"? (emphasis mine)

That's a bold claim. There are a lot of different shoulder issues. I never found that all that YTWL stuff did anything useful for my shoulder at all (torn labrum from Judo), but doing stuff more like the article (closed chain) and doing some of the flexibility stuff from a 'gymnastics for beginners' type program ("Elements" from GMB - in the end I didn't like the program but I still do the warmup/cooldown) also really helped.

Also not getting into impromptu bench pressing competitions with rugby players at the gym was a pretty good idea too.

I had a rotator cuff injury that went on for about two years before I went to a doctor. Their medical advice consisted of "Check Youtube" and they handed me two meters of resistance band.

I was skeptical, but two weeks of rather easy exercises and everything was fixed. It's taken me significantly longer to train myself to remember to use my left arm for anything overhead.

A year ago I had golfer's elbow and it seemed like it wasn't ever going away. After years of lifting very heavy I thought, this is it - I'm fucked. Well fast forward to now and it's pretty much gone. All I did was knock down my weights, did some physio and have slowly started building back up. I'm not back on the big big weights yet but I'm at least on the big weights. Sometimes things have a simple solution.

Just out of curiousity, did you deload on all your lifts or only one the ones that affect golfer's elbow? Substitute things like bench press for those machines that you make a "clapping" motion with?

If I used my right arm I was feeling it. And I don't do much leg exercises so I'd say I deloaded on everything except cardio/anaerobic.

Push-ups and pull-ups are exercises that get you above that "barely acceptable" level of strength that physiotherapy seems to aim to get people to - to perform those movements you need to actually have a level of strength that you can't develop simply with bands. It makes absolute sense that the solution to having a hurt joint is to make that joint significantly stronger.

Both of those exercises have progressions from variants that anyone can do. Like knee pushups where you don't go all the way down. I'd still call that a pushup exercise, and it's the first step to helping your cuffs apparently.

It can be hard to imagine for some of us, but sometimes those bottom rung progressions are essential. Injuries can set you so far away from 'barely acceptable' levels of strength that you end up doing wall pushups for weeks before you can consider doing them from your knees. So absolutely, if that's where you're at, it's a pushup exercise.

And most importantly - there's somewhere to progress to. Moving from the grey band to the blue band isn't a goal, and it has no real reward.

> the solution to having a hurt joint is to make that joint significantly stronger

This may seem like nit-picking, but I think it's important for people with joint damage to understand: you aren't actually making the joint itself stronger. The cartilage and ligaments, bones are not strengthening. Injuries to those tissues are more or less forever.

What you are doing through therapeutic exercise is strengthening the musculature around the joint. The muscles provide most of the support and restraint to keep the joint intact relieving pain and preventing (further) injury. The right muscles, strengthened in balanced form, are what make joints strong.

To nitpick your nitpick, strength training will increase bone density as well as tendon and ligament strength, but not nearly as quickly as muscular strength.

Ligaments and bone density get stronger with strength training dude.. why even make a comment like this with information that is completely wrong

"Dude", we are speaking of injured tissue. A 50% torn ACL does not "get stronger" through exercise. The muscles supporting the joint get stronger. The ACL will always be 50% torn.

Apparently there's some evidence for the ACL regenerating itself.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3293953/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3293953/

Those are interesting links, thanks.

ACL/MCL injuries, and knee/shoulder/elbow injuries in general, are a subject where medical understanding is evolving and a lot of what used to pass as standard care and generally accepted practice is not standing up to more rigorous evidence-based studies. So I'm glad these are being done, but remain very skeptical at this point.

My wife tore her ACL this winter so I had to read up / talk to folks about the current state of care and my conclusion is as I said above: you can improve the support of the joint muscularly, for certain.

In fact everyone involved in high-strain activities should probably be screened for joint muscle strength before they get injured - including folks like military recruits, who have an abysmal knee injury rate that they then suffer from for the rest of their lives.

Anything beyond muscle support improvement is an open question at the very least, as far as my recent dive informed me.

I think the most important thing is to not think that one recipe will work for everybody. There are a lot of different types of shoulder problems that are all getting lumped into "rotator cuff". Try a few different things and see what helps. Also keep watching your shoulders. It's really easy to mess them up again.

Any discussion of shoulder injuries should include, somewhere, the PT exercise known as "plate halos":

https://www.youtube.com/watch?v=ZG0N6JKNUQU

Very, very beneficial and also time efficient as it hits your shoulder from all degrees of motion with a single exercise.

Further, the popularity of crossfit "bumper plates" means that a full diameter plate can be very lightweight. The idea is to work up to a normal 45 pound plate but if you are injured or a smaller female, you can find a 10 or 20 pound bumper plate that is the same diameter. (It's not very effective to use a smaller diameter plate, such as a standard 25 pound plate.)

I would recommend plate halos as a core piece of any upper body strength routine - I do them in my warmups every time I am in the gym.

A friend of mine is a personal trainer who put together an incredibly thorough personalizable program for pull-ups. It's aimed at beginners and includes instructions on building strength even if you can just support part of your weight hanging from the bar. It covers warm-ups, stretches, injury prevention, lots of technique (which is extra important if you're already injured), and how to avoid tensing up and causing more soreness the next day.

The program is at https://thepullupsolution.com/ (He doesn't talk like a content marketer in real life.)

curiously similar name to the works of Jerry Robinson two decades ago, which are still for sale

My own anecdote is that for 7 months I didn't exercise. My shoulders hurt as I slept on my side and rested my header on my pillow with my arm cradling it underneath.

It went away just a week into me restarting my exercise regimen.

Cannot believe that you have described exactly the position that gives me pain for the last 2 months. Both shoulders. Never had a shoulder problem before and I am playing tennis every week for 15 years.

I don't know if they ever tried that but I play with a yoyo, looping style (2A) and it is a wonderful exercise for the shoulder area.

I broke my collarbone two years ago and couldn't use my right arm for almost two months. After that I picked up yoyo and I'm certain that it helped me recover my strength and flexibility.

I experienced a period of forced inactivity which caused a calcium buildup in my right knee. It was very painful to bend past 15 degrees with my weight on it and would collapse under weight. A friend I had who was a big fitness buff suggested I start walking stairs to fix it.

I started out with 5 minutes a day for the first week, then 10 for a week, then 15. I climbed a single story flight of stairs and then turned around and descended, repeating for the workout time.

After a month, the calcium buildup was gone. After three, my legs were so strong I felt like I was bouncing on springs when I walked. I was taking the steps two at a time when I climbed and didn't get winded at all. Great aerobic workout!

The trial registration: https://clinicaltrials.gov/ct2/show/study/NCT02750176?show_d...

I've had frozen shoulder in both shoulders in the recent past. Neither was injured beforehand in any physical manner. I agree with the exercise treatment. It worked for me both times. In the end I found that swimming, breast stroke and then freestyle, worked best for me. For me the first couple of lengths were searingly painful but after ten or fifteen minutes it was really surprising how quickly the pain diminished. Each swimming session kind of followed the same pattern, acute pain at first that slowly faded. After maybe a dozen sessions over six weeks it was pretty much gone. One more anecdote.

Has anyone determined the exact six exercises used in the study? This article mentions: "including push-ups, pull-ups, dips and reverse rows — while the end of the limb is braced." But according to the trial registration, six exercises were used.

Does anyone know where to find the exact exercise regimen used in the trial? Why is this so tricky to find?

The thing to keep in mind here is that studies can only compare the average effects of any treatments they consider. You don't care about that. Instead, you want to know what's going to work for your particular shoulder pain, which might be helped by exercise, or might be something that generally requires surgery.

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