With all the swimming, biking, running, stretching, and lifting you do to train for a multi-sport lifestyle, you put your body through A LOT! Chances are you've dealt with an unpleasant ache or pain. Today's episode is part two in a three-part series covering injury prevention for various portions of your body. In part two, Dr. B.J. Leeper provides an injury-prevention-focused anatomy lesson on a triathlete's upper body! Learn to prevent and treat "swimmer's shoulder," nerve compression in the arms and hands (cyclist's palsy), neck and back pain in your aero position, and more.
TriDot Podcast .120
Preventing & Treating Triathlon Injuries: Above the Waist
Intro: This is the TriDot podcast. TriDot uses your training data and genetic profile, combined with predictive analytics and artificial intelligence to optimize your training, giving you better results in less time with fewer injuries. Our podcast is here to educate, inspire, and entertain. We’ll talk all things triathlon with expert coaches and special guests. Join the conversation and let’s improve together.
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Great show today. Really hope this one helps some folks out. Staying healthy is paramount to improving as a triathlete so we have planned a three episode series to talk about preventing and treating triathlon injuries. On episode 108 we covered leg injuries and today we are coming in hot for part two focusing on the upper quarter of the body which for a triathlete is mostly the shoulder and arms and neck. Excited to get to it. Our first coach joining us for this is Dr. B.J. Leeper. B.J. graduated from The University of Iowa Carver College of Medicine with a Doctorate in Physical Therapy and Rehabilitation Science. He is a Board Certified Orthopaedic Specialist, a Certified Strength and Conditioning Specialist, and a USA Level I Coach. He specializes in comprehensive movement testing and is an avid triathlete himself with over 50 tris under his belt. So B.J., it’s part two of our preventing and treating triathlon injuries series. Are you pumped for our conversation today?
B.J. Leeper: Yeah, thanks Andrew. I’m excited to be back. This should be a fun one to discuss.
Andrew: Also with us today is Coach Jeff Raines. Jeff is a USAT Level II and Ironman U certified coach who has a Masters of Science in exercise physiology and was a D1 collegiate runner. He has over 45 event finishes to his credit and has coached hundreds of athletes to the Ironman finish line. What’s up Jeff?
Jeff Raines: Hey Andrew! I am armed and ready today to chat about arms and shoulders. Sorry man, was that over reaching?
Andrew: Outstanding.
Jeff: It’s a new year.
Andrew: Outstanding.
Jeff: It’s a new year Andrew. I have to bring back some of the awesome dad jokes, right?
Andrew: Yeah, you were really going for it there. Kudos to your commitment to the bit there for sure. Well I’m Andrew the Average Triathlete, Voice of the People and Captain of the Middle of the Pack. As always we'll roll through our warm up question, settle in for our main set topic, and then wind things down with our cool down. Really fun story from an athlete; a TriDot ambassador for today’s cool down so stick around to the end for that. Lots of good stuff, let's get to it!
Warm up theme: Time to warm up! Let’s get moving.
Andrew: Not a triathlon specific warm up question today, but one that I’m excited to throw out to you guys and then to our audience as well on the I AM TriDot Facebook group. Whenever we fire up a movie at home we have the option to go on a brand new cinematic adventure or rewatch a personal favorite. Of all the movies you have watched multiple times over the years, what movie can you best quote word for word as the movie is playing? Now this to me is a great kind of a peek into your personality kind of question. So I’m excited to see what you guys say. B.J., what movie is this for you?
B.J.: Well for me it’s a no brainer. I don’t want people to judge me on this, but it’s The Three Amigos which for those of you who have never watched The Three Amigos it’s like the Mt. Rushmore of comedies. It’s got the comedians from back in the day that are on the Mt. Rushmore of comedy in my mind; Martin Short, Chevy Chase, Steve Martin and it’s just, you know. It’s dumb humor, but it’s hilarious. If you start me at any point in the movie I can take you all the way to the finish. I know that movie and what’s funny about this movie for me too is when I first met my wife back in grad school, we were hanging out at her apartment. She was getting something and she wanted me to pick out a movie for that night just to watch there and I opened up her movie cupboard and she has The Three Amigos on DVD and VHS. This was like back in the day, right? So…
Andrew: And it was love right then and there.
B.J.: I was about ready to get on a knee at that moment.
Jeff: She’s a keeper.
B.J.: Because I was like, she had both versions, both copies there and I was like… I was in love. It was over.
Andrew: And that’s how you knew. Right then and there.
B.J.: That’s how I knew.
Andrew: Jeff Raines, what movie is this for you?
Jeff: You know, I’m actually someone who can’t just watch part of a movie. If I start one I have to watch it all the way to the end even if I’ve seen the movie before.
Andrew: Okay, interesting.
Jeff: It’s just something weird about me. But also if I’ve seen the movie once I’m usually really good at movie trivia and picking up quotes from that movie. So I’ve just got to see it once and most likely I’ll pick it up. Having three kids five and under right now I can quote Moana, Frozen…
Andrew: Nice.
Jeff: …Sing 1. Actually we just took our kids to their very first ever movie in a movie theater last week and we saw Sing 2. I know you’re a fan of Pixar and those types of movies. It was great.
Andrew: Yep.
Jeff: It was great. So all the kid movies, I’ve got those memorized currently, but growing up I watched all the Rocky movies, Indiana Jones, Arnold Schwartsenager, Jim Carey. I can quote all those movies. Probably the most are the Rocky movies. They were just my favorite. I’d throw those out there.
Andrew: This for me– Over the holiday break my wife and I decided to pound through the Lord of the Rings/Hobbit series and then the Pirates of the Caribbean series. We’ve seen all those movies before. We just decided to go back and rewatch all of them and I did not realize that I could quote the Pirates of the Caribbean trilogy pretty much word for word as the movie is playing and that’s not like me. I don’t do that with other movies. So that’s the answer for me. I’m really excited to hear what our audience has to say because I know some folks have those movies they just love going back to time and time again that they know every single word to. So folks, go to the I AM TriDot Facebook group, find our post asking this question and let us know what movie is this for you that you can quote word for word every time it comes on.
Main set theme: On to the main set. Going in 3…2…1…
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Andrew: We put our body parts through a good little bit as we swim, bike, and run our way to fitness. Some folks tend to stay healthier easier and some of us find ourselves experiencing nicks and niggles on a regular basis and that’s why we’re visiting with Dr. B.J. Leeper to learn how triathletes can prevent and treat triathlon injuries. If you have not listened to episode 108 I highly recommend visiting that episode where we did this with the common leg injuries and today we move onto the shoulders and arms and neck and upper quarter. So B.J., how common are these kind of injuries as opposed to leg injuries?
B.J.: Yeah I mean in general I think upper quarter injuries are very common. In the clinic it’s one of our top three areas we treat. So the top three areas are typically going to be your lower quarter knee injuries, upper quarter typically shoulder, and then your spinal related injuries. So in the outpatient orthopedics world it’s very common. In triathlon, in particular triathlon related upper quarter injuries are a little less common. We’ll get into that a little bit more.
Andrew: Okay.
B.J.: In general with triathlon the limited research we have with triathlon tells us that about 75% of triathlon related injuries are overuse injuries and like we’ve discussed in previous podcasts, 75% of those are typically lower quarter injuries more related to running. So if you look at the statistics research wise for the limited research we have with triathlon, generally you’re going to see around 10% at most in triathlon is related to upper quarter injuries with the most of that being related to the shoulder and obviously more swimming related.
Andrew: Yeah that’s definitely more weighted to leg injuries than I would have guessed. We started with the episode in this series on leg injuries because of that, but that’s a pretty substantial difference. If you struggle with shoulder pain in the swim or if you’ve had a bike wreck like Jeff where you tore something or hurt something or broke something it’s not as common, but there definitely are upper quarter injuries in our sport. So B.J., kind of walk us through what are the most common upper quarter injuries related to triathlon?
B.J.: Well just like you said Andrew, I think there’s kind of two categories. There's the category that you just mentioned with Elizabeth’s example where you’ve had a traumatic injury which is more obvious; it’s bike crashes, falls. That’s going to lead to your fractures, dislocations. Typical bike crashes and various things are going to involve your clavicle and kind of like Jeff was saying, areas around the AC joint, the acromioclavicular joint. But the majority of what we see in triathlon is going to be in the second category which is your non-traumatic injuries. So more of your overuse injuries and occasionally you’ll see this in the upper quarter with triathletes doing complimentary weight training, but again most commonly you’re going to see swimming related injuries that affect the shoulder. So to break those out just generally, not to get too technical into all of these things, but you’re going to hear these terms thrown around a lot with upper quarter injuries for triathlon. With the shoulder you’re going to hear the term swimmer’s shoulder which is really a catch all term which encompasses a lot of these other things we’re going to talk about. Also you’ll hear rotator cuff impingement syndrome which is another; in the orthopedic world it’s kind of another one of these catch all terms which isn’t always adequately defined. So within the shoulder you’re going to see– within swimmer’s shoulder if you want to call it that, or rotator cuff impingement, you’re going to see those subacromial structures. The acromion is kind of the arch of bone of your shoulder blade where you have a lot of structures that lie underneath that. So you’ve got your subacromial bursa which is a fluid-filled sac between that arch and the supraspinatus tendon so there’s a commonly inflamed area where you’ll get subacromial bursitis. There’s tendinopathies where you can get inflammation of those rotator cuff tendons underneath that arch. That can include all kinds of different muscles we can get into, but then you’ll also see with swimmers often instability where they’re very mobile, they’re very lax in that glenohumeral joint where they’re going to have instability most commonly kind of the anterior inferior portion of the shoulder, but can be multidirectional. Then again, like we were discussing with Jeff, that area of the AC joint where the clavicle kind of meets the acromion or the outer edge of your shoulder blade and then you’re typical muscle strains that might be involved with upper quarter like peck, lat, upper trap. So there’s a lot of different areas we can kind of categorized within the upper quarter or shoulder area with regard to triathlon, but again the two main categories are going to be traumatic and non-traumatic overuse.
Jeff: I would just second that. In my experience and especially a lot of the athletes that I coach, I’d say hands down the most upper body injuries are due to overuse injuries and a lot of it is probably due to improper mechanics and that overuse and kind of thinking that if the form is bad that people are becoming more efficient at being inefficient and the overuse and over time… I mean little things can affect that. A bad bike fit, inefficient form while swimming, but we see it a lot also that the hands tingling while you’re riding a lot of times there’s too much drop between the handlebars and the saddle. That ulnar nerve is not protected by muscle or bone so when that pressure is put on there and the bike fit is too aggressive too soon or too much weight or gripping too tense on those handlebars we see that a lot. Of course the swimmer’s shoulder that B.J. alluded to and then neck pain I think is a lot of open water sighting, looking up, swimming a little different in open water than you would in a pool and then also maybe not practicing that aero position enough. We see a lot of those and probably are the most common.
Andrew: Yep. Thanks for identifying all of those guys. That definitely tracks with the things I hear and see our listeners talking about and asking about. I’m excited to dive into all these injuries and dive into what we can do to prevent them and what we can do to treat them. So B.J., what is it about our shoulder in particular– really there as we were talking through a lot of those issues a lot of them sound shoulder related. What is it about our shoulder and it’s anatomy that makes it so prone to injury?
B.J.: Yeah, the shoulder is such an amazing joint and it’s kind of– the bottom line with this one of the reasons I think it’s just so prone to injury is because the more that you are given the more that is required. So the shoulder being one of the most mobile joints in the body, it’s required to stabilize itself through a ton of range of motion and it’s very different than like the knee that’s more of a hinge joint where there’s just a certain range that needs to be stabilized. The shoulder needs a full array of mobility and stability within that range. So I think a lot of times because of that; because there’s such a high mobility component to the shoulder, it again requires more to stabilize that. A lot of times I think that’s an area we tend to neglect or we lose and because of that; because the shoulder is so mobile that becomes the path of least resistance when the body’s trying to compensate somewhere. So because it is so mobile, the body just thinks “well, let’s pass it to the shoulder. It can move around enough to try to figure something out.” and as a result everything tends to lock up around it and what’s really interesting and we can kind of discuss a little bit more as we go, but the shoulder, when people feel tightness in their shoulder, a lot of times they think they have a mobility issue. A lot of times that’s not the case. They feel tightness and it’s an attempt of their body to actually put the parking brake on to protect themselves because there’s too much mobility that’s unstabilized there. So you’ll feel stiff and you’ll think that naturally I just need to stretch, stretch, stretch, but the reality is your shoulder is already lax, it’s already losing the battle and your body is tightening up muscles around it to try to stabilize itself because you’re lacking the requisite fundamental stability to own that joint and it’s a big misnomer. I think a lot of athletes in general and not just triathletes get into is thinking they have a mobility issue when that’s not really the case.
Jeff: Also I would imagine that people have a dominant arm or maybe even better flexibility in one shoulder than the other and so that may play into an imbalance using one arm versus the other or maybe you just sleep on that same shoulder every night and maybe that kind of causes one to tend to be more injury prone or less range of motion or something than the other.
B.J.: Yeah exactly. Asymmetry is a big predicator for injury and within the shoulder there’s a lot of potential for that. There’s a lot of potential for muscular imbalances and imbalances of stability or that motor control. And again going back to why the shoulder is sometimes more injured, a lot of times because there’s more moving parts again it requires more and we’re going to talk a lot about the scapula which is kind of the base of your shoulder and that’s a big area that can get out of rhythm so to speak and cause a lot of dysfunction too.
Andrew: I just want to point out to folks because I always find this fascinating. Jeff you kind of mentioned sleeping on one side versus the other and I’ve seen Jeff Raines talking with runners about their run form and he can say to them, “Just watching you run you sleep on your right side don’t you?” And they’re like, “Yeah I do. How do you know that?” And he can break down for them…
B.J.: Creepy!
Andrew: Yeah he can break down what it was in their run form that showed you that they probably sleep on their right side. I’ve had conversations with B.J. about things that hurt on my body and B.J. has been able to say, “Are you left handed or right handed? You’re left handed right?” And it’s like, “How do you know these…” and you can tell just by your depth of knowledge and what you’re seeing and hearing from an athlete– It’s just wild. It’s just wild watching you guys bring your textbook knowledge into the actual applied science of the movement of the body. It’s just super cool to me. So I just wanted to point out that both you guys are freaks in that way as we move on through this podcast. So when we talked about specific lower quarter injuries on episode 108, we talked about specific things like plantar fasciitis, IT band syndrome, etcetera, etcetera. Many of those injuries don’t necessarily need to be treated at the source of the pain, but rather they are signs of a problem somewhere higher up the chain of movement. Is it this way with shoulder injuries as well or is the shoulder a case where the spot that hurts is the spot where the problem likely is?
B.J.: Yeah, well I don’t know if I’ve ever told you this Andrew, but that’s a great question. It’s probably the first time that you’ve ever heard that from me.
Andrew: I often hear that I ask million dollar questions.
B.J.: Yeah, you’ve got a great question.
Andrew: I’m still waiting on that million dollars.
B.J.: To me that’s the way the body works. We move in patterns and not simply parts and a lot of times we tend to think about… we’ll get caught up in the trees and lose the forest. So whatever analogy you want to use I think it’s definitely pertinent to the shoulder as well. So the shoulder, like we’re saying, it’s such a mobile area that’s one of the last links in the chain that sometimes gets the buck passed to it and it has to figure it out and a lot of times if that’s done over time like we’re talking with overuse injuries, it sometimes just can’t keep up and it breaks down. So I think a lot of times that we have to look up the chain or in this case we have to look at the axial part of the body; the shoulder blade and the spine to be able to look and make sure that you’ve got the shoulder set up for success. The reality is when you have symptoms of the shoulder that is your body telling you that there’s an injury there. There’s something going on there. So even though the area that technically needs to be addressed from a symptoms standpoint may very well lie in the shoulder, a lot of times the root of that issue is not in the shoulder itself. It’s somewhere else and the shoulder is just the symptom. A lot of times with this I think about our platform of stability. We talk about this specifically with triathlon in the swim, bike, and run. If you look at each discipline within swimming, biking, and running I always think about where is the body getting it’s stability from? Where are the impact points where you’re gaining stability? So for example on the run it’s your foot hitting the ground. That’s your point of stability. For the bike it’s where your arms meet the aero bars or the handle bars. It’s where your seat hits. It’s where your foot touches the pedals. Within the swim, if you think about it, we don’t have a fixed point of stability there so really the stability that comes from swimming is you. Your body is the platform of stability and it’s you in the water where you create that push, that pull to propel yourself forward through the water, but it’s not fixed like the ground. It’s not fixed like the parts of a bike. So the reality is if your foundation of stability within the swim is shaky, meaning that your core platform or your shoulder blade platform as you’re moving through the water is insufficient, guess what’s going to have to make up that last link in the chain to try to propel you forward through the water? It’s going to end up being your arm.
Andrew: Your shoulder.
B.J.: Your upper quarter. Your shoulder. So it’s interesting to me when we think about that and I find it no coincidence that when you look at Olympic swimmers their bodies– there’s no doubt they have core, right? When you look at a swimmer, arguably you could say they have the best abs known to man.
Andrew: Yeah.
B.J.: And that’s their foundation. Their platform is their core as they use their arms to propel themselves forward. So if there’s an energy leak there through the core or through the shoulder blade it’s going to have to be made up in the shoulder. So that’s why you have to address all of those parts when you’re talking about upper quarter injury in the shoulder. It’s not just the shoulder. Otherwise you’re missing a big, big piece.
Jeff: Yeah, you know, the human body is designed more to pull than it is to push and if you think about it a lot of people want to run faster, they want to hit the ground harder maybe so they’ll travel further in each stride, right? DPS, distance per stride, but really you want to think lift, lift, lift. We want that elastic chain is where we’re going to get that propulsion. Even cycling– you know, most people are overly quad dominant by nature and a lot of people are focusing on the push, push, push so much that they kind of bail out of the lift phase of that leg because they’re already thinking about pushing down on the pedal with the other leg. So thinking lift or that elastic chain or a little bit pulling more than pushing can help a lot in injury prevention.
Andrew: So an athlete begins to feel pain in their shoulder during a swim session; how can they determine if it’s leading to a serious problem or if it’s just typical training soreness that will go away on its own?
B.J.: Yeah like any training I think there’s going to be the natural muscle breakdown that you get from training, the adaptations that you’re desiring to improve and to build resiliency within those muscles. But there’s a difference between that and then like we’re talking about determining if it's a serious problem or injury. One of the biggest predictors I think of potential injury is what previous injury history do you have? We know within the research of various injuries is that’s one of the biggest predicting factors is what is your previous history of shoulder injury? Have you had a tweak in your past or a traumatic injury in your past like we are talking about where that may have set you up for potential breakdown. The other thing you want to consider is, at what point during the activity is it bothering you? Is it only bothering you afterwards? Is it, again, that ache that might be more just residual muscle soreness that’s not uncommon, or is it something that it’s starting to affect you during? When you get to a certain point within the duration of your training or within the intensity of your training, if you have to pull extremely hard to try to increase your pace, are those things starting to affect it where you know it’s specific to one of those two things; duration or intensity. Those can be big signs that there’s something going on that’s not natural. Then the other big thing to kind of assess to know when you might have to peel back the layers a little bit more to diagnose is, are basic fundamental movements outside of water naturally just starting to irritate or bother you? So for example, just taking on and off a shirt or grabbing a wallet from your back hip pocket. There’s basic things you can look at. If those things start to give you discomfort– and we’re not always talking about pain. The question we always ask in the clinic is “do you have any discomfort with this movement?” and we might take somebody through a basic screen or test of looking at a fundamental pattern like we’re describing and if anything other than a no– you know if they’re like, “well no it doesn’t really,” that’s a yes.
Jeff: Maybe.
Andrew: Okay, interesting.
B.J.: So when you pose a question it’s not always pain, but do you have discomfort? Any statement other than a no is a yes. If it’s immediate, “nope, nope” fine. But if it’s like “well, you know…” yes. That’s something to be evaluated.
Andrew: Interesting.
B.J.: Yeah and so those are kind of the tip of the iceberg factors so you can kind of start to evaluate and really your body is good at telling you what to listen to. So I think your natural intuition, nobody knows your body better than you. That’s what I’ve always told every single patient that I’ve had where I might be the expert in knowing certain things about the body, but they know their body better than anybody. So if there’s any doubt, any intuitive doubt that something’s not right have it evaluated. It’s way better to evaluate it before it becomes a really serious problem.
Andrew: So Jeff, as you coach your athletes I know swim form is a huge part of those conversations when you’re trying to make improvements in the pool and in swim splits and swim thresholds. When you have an athlete reporting shoulder pain from their swim sessions, what is usually wrong in their form that can be causing the pain?
Jeff: Man, good question. I mean, that swimmer’s shoulder, that bursitis is huge and that’s kind of what you immediately go to in your mind. “Hey my shoulder feels a little tight or you know something.” That bursitis, the bursa under the shoulder blade and B.J. really broke it down better earlier, but it’s part of your scapula and it gets irritated because the space between your humerus and that acromion is narrow and it narrows even further with overhead activities. So swimming, you’re reaching out forward and that’s kind of the epitome of overhead activity. So I’ve seen a lot of shoulder and rotator cuff injuries over the years in athletes mainly due to inefficient swim form and these could be due to a recovery arm that’s too close to your body, right? You push the water down to that bullseye drawn around your feet, you engage that tricep, and you’re ready to bring that arm forward above the water and a lot of people will really have that elbow super high to the sky, really squeeze their back. I like to promote a little bit of a wider recovery arm as it comes forward on that recovery stage, but we see that a lot. So a lot of that swimmer’s shoulder can be due to a recovery arm that’s too close to the body as it’s coming forward. We also see the start of the catch phase with that arm reached out in front of you, that overhead position, starting a catch phase with that hand too high where maybe your arm is straight kind of even to the surface of the water. So we want to have that wrist lower than the elbow and the elbow lower than the shoulder. So a hand that is a little bit deeper, when in doubt, when you start that catch phase; so an arm too straight can cause that. Then as you’re progressing through the underwater stroke, that middle phase, the diagonal phase it’s sometimes called, it’s actually more so referred to as the power phase of the stroke to where you’ve caught the water, you’ve started pulling it towards your face, towards your body, and then you’re powering through it. You’re accelerating through as you progress through that. So when you do that with an arm that is too straight we see that a lot as well in swimming and so we want to have a little bit of bend in the elbow. I think that’s a swim form episode which we’ll talk about on another episode. But kind of lastly, I think I’ve also seen upper body injuries due to too aggressive of a bike fit maybe when you’re not ready or maybe just the aero pads are too narrow and you need to widen them out or even angle them a little bit. They don’t have to be perfectly parallel to the top tube. Then we see a lot that– actually the last year or two in the sport we’ve seen more so the pros especially really hiding behind their hands kind of like they’re praying at the dinner table with both elbows on the table. They’re kind of hiding…
Andrew: Yeah.
Jeff: …behind that praying mantis hand. We used to see that forearm be closer to parallel to the ground and a lot of people really tensing their wrists as they’re gripping those aerobars. So we want to keep a wrist that’s slightly higher than the elbow so that’s something else that we always see. Then neck injuries, the same thing. A little trick maybe in aero position is to keep the head down, but use a little bit more of eyes up instead of just overstressing that neck. We’ve said it before and everyone kind of knows it, but you always choose comfort over aggressiveness on that bike fit. So don’t rush into having a seat that’s four inches higher than your aero pads especially for long course.
Andrew: Yeah, I was riding with a buddy of mine pretty early in my tri career and I had just gotten a tri bike. I had done a few rides on it and very early thankfully I had a buddy of mine riding next to me and he was like, “hey, head down, eyes kind of look ahead up the road with your eyes, not your head” and that was something I was able to– a lesson I was able to learn early thanks to a buddy of mine.
B.J.: I think Jeff brought up some really good things there and I think one interesting question–
Andrew: Well done Jeff. Well done.
B.J.: Yeah, well done Jeff. I think the really interesting question that comes from some of this is looking at does bad swim form or bad technique come from poor movement, poor shoulder mobility…
Andrew: Ummm, yeah.
B.J.: …or stability? Or does bad mobility, does bad form come as a result from that directly or is it vice versa.
Andrew: It’s a real chicken or egg situation.
B.J.: Exactly. I feel like our bodies are smart enough to try to figure out a way even though that way might be dysfunctional and it’s sometimes set up for dysfunction because we don’t have the correct requisite mobility especially through our spines. So with regard to the swim, what I feel like happens quite often as athletes, as swimmers, we might lack proper thoracic spine extension and rotation. So instead of getting the desired body roll, body rotation through the water like we know should happen with the swim, we tend to stay pretty stiff and stagnant through the spine and as a result like Jeff was describing, the arm tends to get out of position. What’s really interesting to me too is that the position of our propulsion and our catch is a very common position that we use in physical therapy in the clinic to test for provocation of those subacromial structures. So it’s an impingement test that looks just like the catch portion of your swim and naturally if things are healthy and happy we should be able to assume that position. Like Jeff said, there’s not a lot of space there, but naturally we should be able to assume that position without any irritation and a lot of times with overuse if the body is compensating for some of these dysfunctions that area gets irritated and then that catch position is just as provocative as anything and that’s why we use that type of position in the clinic to actually test those structures because it’s a good indicator of something isn’t right there.
Andrew: I also want to add that for anybody who thought that two minutes of Jeff Raines talking about swim stroke form was interesting, Jeff you kind of teased for a brief second, we do have a swim stroke episode coming. This current episode is #120 that you’re listening to right now, it’s happening in real time. Next week, episode #121 is a run shoe episode. We have some guests coming on to talk about just the most modern day run shoes that are out on the market right now. Then episode #122 will be coach Jeff Raines and TriDot coach Joanna Nami doing a deep dive into how to refine your swim stroke. So really excited about that just a few weeks away. But back to shoulders and upper quarter, I think for a lot of triathletes dealing with shoulder pain in the pool, it’s usually just a slight-to-moderate amount of pain or soreness and often we can train through it and sometimes need to train through it to get to and through that next race event. I certainly this previous year in 2021 trained through some shoulder discomfort in the pool knowing I had Escape from Alcatraz and Ironman Waco on the calendar. What can we do to manage shoulder issues and upper quarter issues until we get through the backside of race day?
B.J.: Yeah and I think that’s what we struggle with a lot is when do we take time off to really address and get to the root of things or when is it just can we get away with just managing it and getting through, getting by to get that race accomplished. Again, sometimes your intuition can guide you, but sometimes you can’t wait. Sometimes you need to actually start addressing it and sometimes it can be an easy thing where you don’t need to wait to truly address it and we’ll just keep putting bandaids on and try to work around it, but I think it’s wise to pursue some evaluation and treatment because you might be able to incorporate that very simply as you continue to train so you can ensure that you get to the starting line. But when we do try to just simply manage, you know those things that we have to do to try to get through, a lot of times you have to first address if there’s any chemical irritation present. So if there’s inflammation and the best way to think of inflammation is like a sunburn of your skin, it hurts to the touch. A little input that causes it to be irritating. If that’s the case you definitely need to be addressing the chemical irritation first. That’s your typical rest, ice, NSAID approach, but again you have to get to the root of it. I think sometimes we can modify with volume; changing our volume, changing intensity. Sometimes we’ll advise avoiding heavier pulls so maybe you scrap the paddle work for a period of time to limit that, but again I’m not a big fan and obviously this is what I do, but I’m not a big fan of just trying to brush things under the rug and just pretend
Andrew: Yeah.
B.J.: …there’s not an issue there. So yes there are things you can do to get by like controlling chemical inflammation and modifying your activity, but it’s like driving a car in my opinion. You could have a deficit in your car and it might be okay when you just drive around town, but you go on that long road trip it’s not a matter of if it’s going to break down, it’s just when. So I think to truly be good to ourselves we have to look into that before it becomes too much of an issue.
Andrew: So B.J., once our shoulder pain is becoming a serious problem and we know it’s a serious problem, we want to address it; what steps should we take to get shoulder pain in particular resolved?
B.J.: Yeah so I think there’s a couple things we can do on our own before we maybe need to seek professional help and I think this is kind of something we were discussing offline earlier. Just talking about how can you assess for asymmetries in yourself? How can you assess for some of these impingement issues in yourself and there’s really some simple ways you can do it. I think a lot of times our intuition can tell us where the area is that’s being affected, but sometimes we need to be able to screen or have somebody else screen us in order to figure that out. So there’s some simple things and if we start kind of at the base, if we start at the thoracic spine, the thoracic spine is amazing with allowing our bodies to move through extension and rotation. Especially with the swim we need to be able to assess rotation and a real simple way– and this is something I’ll try to describe verbally. If you were to sit kind of cross legged, Indian leg style in the middle of a doorway facing the doorway, kind of perpendicular to the opening of the doorway. So you’ve crossed your legs and your legs are squared right up into the doorway of the door jam. If you took a dowel or sometimes we’ll have people just take like a Swiffer handle or a broom stick or something where you could place it across your shoulders with your elbows down. You don’t want your elbows up, but your elbows are close to your body, your arms are crossed and your hands are touching each opposite shoulder and you’ve got a dowel going right across your shoulder to kind of be an indicator of rotation. Without letting your lower body move, so keeping your legs crossed, can you rotate and touch one side of that dowel all the way to the door frame? Then testing that and just looking at it on the other side. If one side is significantly easier than the other or one side causes discomfort compared to the other, that’s an indicator. That’s a big indicator of asymmetry. So that’s a fundamental movement of screening your thoracic spine rotation. Do you have an adequate amount of rotation? Then looking at like we were saying that catch position in the shoulder, if you take your shoulder that’s aggravated and really you want to compare both sides, but if you take your shoulders and reaching your palm across to your opposite shoulder, keeping your palm down on your opposite shoulder, lifting your elbow towards the sky as high as you can without letting your opposite palm come up, if you have discomfort or there’s significant difference in mobility between one side and the other, again that might mean that there’s significant dysfunction that needs to be further evaluated. Especially if there’s pain in any one of those screens, you don’t just have a movement problem, you might have a medical problem. So those are some of the things you can do to kind of test yourself and look, but the reality is once you’ve assessed and you kind of know where the deficits lie, focus first on mobility and again like we were saying earlier, sometimes it’s a mobility restriction in the muscles, soft tissue extensibility dysfunction, sometimes it’s a mobility issue at the joint, but regardless you need to make sure you’ve cleared mobility before you start to work on stability or what most people would describe as strength. if you’re just saying, “well I probably just need to be stronger in my shoulders,” but you haven’t addressed your underlying mobility issue whether it’s at your T-spine or your shoulder, you might just be putting fitness on dysfunction.
Andrew: Interesting.
B.J.: So you might just be making something even worse by trying to strength train. So you need to address things in that proper order and again, if there’s something that just doesn’t seem right, that’s your indicator to seek more professional evaluation to get it addressed and that’s probably one of the biggest steps to ultimately getting it resolved in the right way.
Andrew: As you were talking I googled thoracic spine just to see an image, kind of a chart of where on our body that was. Obviously it’s the spine, but just more specific. I definitely, 100%, B.J., misspelled thoracic. I was spelling it like Jurassic, as in Jurassic Park, but with a t-h-u instead of j-u. So I did the little double s in the middle and that is not how you spell thoracic spine. I now know that thanks to this podcast episode. A lot of times, B.J., we’re throwing out hypotheticals, if people are feeling this they should do that. Because everybody’s scenarios and what they’re going through is specific. So on this episode, since I have dealt with some shoulder pain in the last six months, I just wanted to use myself as a case study because I want everybody to kind of hear what it’s like to have you break down an injury for them and so really quickly I’ll try to give the 60 second version for everybody on the background of my shoulder injury. My left shoulder, when I was a young 20-something not a triathlete, just a runner, would go to the gym to workout after work. I sustained a left shoulder injury where my left shoulder just from overuse was really hurting, just all the time. It was wearing down in workouts. I was in pain in between workouts. So I went to an orthopedic specialist. I got it looked at and I actually had some bruising of the bone there on my left shoulder. Basically the orthopedic surgeon he was like, there’s nothing really we can do. If you wanted we could make an incision and take that part of your collar bone out and so you wouldn’t experience the pain, but you would have less collar bone there and that kind of sounded freaky to me so I declined that invitation. Basically I just knew I needed to be a little more careful in my workouts. He explained to me that that injury is seen in people that do a lot of pushing motions and Jeff he talked about pushing versus pulling motions earlier. So doing a lot of bench press type workouts and a lot of things– pushups and I wasn’t doing enough pulling motions. So he was like add in some more pull motion based stuff and be careful with it and I just kind of had to manage it. So fast forward to me being a triathlete. My left shoulder in the pool would from time to time experience more discomfort than the right shoulder. It does have that previous injury in its background and in the leadup to Escape from Alcatraz Triathlon I was doing a pool session. I wasn’t doing anything out of the ordinary, I came off the wall and just in that motion of coming off the wall, I’m in streamline, my arms extended forward in front of me and I always take my first stroke with my left arm and I went to make that pull motion and my hand goes under the water, I go to start pulling back, and I definitely felt a tweak, a twinge in my left shoulder. I remember thinking, “mmm… that didn’t feel right.” I kept swimming. I could keep swimming on it. Basically for the next couple months as I trained for Escape from Alcatraz, as I trained for Ironman Waco, that discomfort was in my left shoulder every single swim. Every single time I came off the wall I tried to take my first stroke with my right hand. I tried to not put my body weight on my left arm when it was extended in my rotation and I just kind of had to manage. I basically cut out doing fast intervals. I kept it threshold and lower and I really had to be careful when I was doing threshold sets. So that is a very specific example of myself in the pool, a very recent shoulder injury, something that I’m still dealing with because frankly after Ironman Waco I kind of took a couple months off of swimming just with travel and work and what not. I just kind of took time off in the pool and my first session back in the pool in late December, almost a full two month break for my shoulder, I went to take my first pull with my left arm and boom, that same discomfort was still there. So it was clearly something there–
Jeff: Do you breathe– out of curiosity do you breathe more predominantly or comfortably to your right side.
Andrew: Yes, great question Jeff. I am a bilateral breather. I’m very comfortable on both sides. I typically do every three strokes I take a breath so I’m pretty well practiced in breathing both ways. So that is out. But B.J. that’s all the background I think you need. That’s probably even more than you might need and thank you everybody for listening to me whine about my left shoulder, but I want people to see armed with that information, what would you tell me to do and how would you diagnose what’s going on in my shoulder?
B.J.: Yeah and it’s a great case example because a lot of these things we’ve been talking about before this are injuries that are more subacromial. So it’s underneath that acromial arch where the shoulder is more affected at the glenohumeral joint or kind of the ball of your shoulder. What you’re describing, Andrew, is more along the AC joint where it’s basically where your scapula meets your clavicle or your collar bone. So that little bump on the top of your shoulder where those two structures meet, that’s your acromioclavicular joint or your AC joint. So that’s not as common of an area, but it’s definitely an area that can become affected and like you were describing, one of the best things you told me as far as information to try to evaluate and help is that previous history of injury with overhead or pressing, pushing from the weight room. A lot of times that area can become irritated where the technical term for it is you’ll get acromioclavicular osteolysis where it just means the distal end or the outer part of your clavicle starts to become irritated for lack of better terms and that is something that could lead to osteoarthritis of that joint down the road…
Andrew: Oh cool. Cool, cool, cool, cool, cool.
B.J.: …if it’s not addressed.
Andrew: Yeah. Looking forward to that.
B.J.: It’s a joint just like you have cartilage in your knee. It’s got cartilage there. It’s a joint like any other joint, but because when you move your arm overhead it’s kind of an accessory mover of your shoulder. It’s part of the rhythm, what we call the scapulohumeral rhythm. So as you move your arm upwards, your glenohumeral joint or the ball of your shoulder is what typically initiates that motion and you have about 120 degrees of mobility normally there. So think for example of arm straight up by your ear is 180 if you could move that far truly, 120 degrees of that motion happens at the ball of your shoulder.
Andrew: Okay.
B.J.: Then after you’ve taken up that 120 degrees, the remaining roughly 60 degrees happens through your shoulder blade.
Andrew: Wow.
B.J.: And your shoulder blade articulates at your sternum. So you’ve got your SC joint and then it articulates at the clavicle as well. You’ve got your acromioclavicular joint or your AC joint. So those two joints make up the remaining roughly 60 degrees. So what can happen with that scapulohumeral rhythm if there’s an injury to one of those articulating joints or the shoulder blade that rhythm gets off and all of a sudden a lot of times you’ll see what they call scapular dyskinesis which means for lack of a better term, you’re shoulder blade is getting sloppy where it starts to move early and then by the time you’ve already gotten to that overhead reach position you’ve already taken up all the motion in your shoulder blade so there’s no more room for your shoulder blade to move. It’s already superiorly translated. It’s already upwardly rotated and then the last link of the chain is just jamming down on that AC joint or wherever it might be. Sometimes it’s more the subacromial space in the glenohumeral joint. Sometimes it’s more that AC joint like you were mentioning where your body’s just trying to jam through that joint to get anything else it can…
Andrew: Yeah.
B.J.: …because maybe there’s a lack of thoracic rotation already so it’s already having to make up for that. So there’s all these things that can lead to that dysfunction where we know where you hurt, you know where you hurt, but the root cause of what needs to be trained to fix that might not be at that AC joint. Like you could cut out that lateral third or distal portion. They call that a distal clavicle excision, DCE, which that’s like the bandaid treatment. That improves where you hurt and it can buy time, but it doesn’t change your dysfunction and even like you said. You rested for a while, it felt better, you go back to the pool, it’s the same old thing because it’s a motor control issue. It’s that rhythm issue. So what you have to start to do is evaluate further to figure out where is the lowest hanging fruit that needs to be addressed? Is it my T-spine? We haven’t even talked about the neck, but a lot of times the neck will start to put the parking break on to try– it thinks it’s helping that whole process, but you’re starting to develop upper trap tightness because it’s trying to limit that upward rotation of the shoulder blade or put a block on that and all of a sudden what’s happening is you’re just getting tighter and tighter and after a swim you realize, “gosh, my neck hurts now all of a sudden” and that contributes to that dysfunction. So it’s kind of this cyclical in nature where you hurt, because you hurt your body tightens up, because you’re tight it causes more dysfunction, you hurt more. So it’s kind of this cycle that you have to break and a lot of it ties back to scapular stability, but just like we were saying earlier, that can’t happen until we’ve cleared all the areas you need to be mobile with and also fairly symmetrical with. So that’s kind of a long winded breakdown, but again, I think that case example allows us to talk about things in a very good way to address all those parts that really need to be addressed to clean something like that up for long term. Otherwise, we’re running that risk of early onset osteoarthritis in that particular joint and that’s obviously something we don’t want.
Andrew: I wanted people to hear just that entire detailed breakdown because I’ve had yourself, we’ve talked one on one about certain things I’ve dealt with. I’ve worked in the past with different physical therapists at different seasons of my life and gotten great wisdom like that from them. We tell people in these episodes, get screened, get screened, get screened. Figure out what’s going on. Figure out what the root cause of your problems are and I want people to hear like when you go to somebody as knowledgeable as B.J. Leeper, as knowledgeable as a fellow PT, that’s the kind of knowledge they have and that’s what really helps you get to the root of what you’re going through is the way– I mean when I was telling you that issue and just now when you were showing “okay it’s happening when your arm is extended?” It’s like, “yes that’s exactly when it happens. It happens when my arm is extended out in front of me in my stroke” and you start breaking down what’s going on. Super fascinating stuff and I would encourage anybody if you’re experiencing some issues, some problems, to get screened. Have somebody more knowledgeable than yourself take a look at what’s going on there. There’s no foolproof way to prevent an upper quadrant injury or shoulder pain, obviously, but what are some things to kind of raise the odds that that part of the body stays happy and healthy?
B.J.: I think the thing we say a lot, and I’ve said this before in previous podcasts I know, is you need to be a sniper. Nobody goes to sniper school just to learn how to shoot. You learn how to aim and that’s really the jist of it. When you’re trying to keep that area of your body happy and healthy, you have to know your deficits. You have to know where your weaknesses truly lie in order to train them effectively. The tendency is with conventional treatment in the past of shoulders whether you’ve had pain or not it’s like, “oh I know I need to strengthen my shoulders.” So the conventional history will show, “well here take these bands and you need to move your shoulder in this rotational direction, side to side, holding your elbow at a 90 degree angle” and while that’s isolating the rotational muscles of the shoulder, it may be strengthening them in isolation, it’s not really training your ability to stabilize. You’re kind of targeting an area in a nondescript way. It's like saying that you know you need to improve your squats so you’re just going to strengthen your legs by doing knee extension. The reality is, no, you can isolate that muscle, you can strengthen that muscle but you need to squat to be able to squat better. You need to be able to train your deadlift, your hip hinge to be able to squat better. The same thing is with the shoulder. You need to realize that your shoulder moves in patterns and what’s really interesting to me is that the way we naturally were designed and naturally developed, when you’re a baby rolling around on the floor, growing up and going through those phases of development where you’re crawling, you’re pushing yourself up, by the time you get to your feet you’ve established a certain amount of shoulder stability and at no point did you do PT 101 of rotator cuff exercises moving your arm in and out in that rotational manner, but you earned the right to push, pull, lift, carry by the fact that you rolled around, reached with your arms, you pushed yourself up, you crawled weight bearing on your elbows. So there’s certain things we don’t have to reinvent the wheel with in my opinion. We can go back to basic primitive movement patterns and what that looks like in the gym is it’s planking, it’s reaching, it’s rolling, it’s diagonal patterns, it’s things that tend to be a lot more functional than just this isolation. I tell this to people all the time where if you’re going to the gym and you’re still doing the same six lifts you did in high school, you’re probably missing the boat. You’re probably already strong in those areas. It’s not like those are always bad things, but attack your deficits. Do the things you know you suck at and for a lot of us as triathletes, specifically even cyclists, you tend to not be very good in your upper quarter. So I think that’s an area you have to attack your deficits. But if you know, okay I need to attack my shoulders, have some guidance if you’re not sure. Have somebody help evaluate you, show you what the specific things are that you can address and address them in a very specific way. It might not be as conventional as what you might see other people doing in the gym, but it might be the best thing for you.
Andrew: So with all that, we’ve talked about shoulder injuries specifically pull, swimmer’s shoulder. I think a lot of folks that’s what they’re dealing with if they’re dealing with an upper quadrant, triathlon related injury. B.J., you just talked very, very well about upper quadrant injuries in the gym which is another place we can pick up things like that. In the Andrew Harley shoulder case study, I first picked up my shoulder injury in a gym so it’s definitely a place we need to be careful in the movements we’re doing and intentional with the movements that we’re doing. The only other avenue I can think of where having an upper quadrant injury would be common is through a bike crash and Jeff Raines, earlier you mentioned your one upper quadrant injury was bike crash related. We talked about Elizabeth James having a bike crash related upper quadrant injury. Whether we get struck, whether we hit debris on the road and go down, or whether we just fail to unclip at a stoplight and fall over embarrassingly on our own arm or shoulder, how should we handle it when we injure our upper body in a bike crash?
B.J.: Yeah, I think any time there’s a trauma like that, seek some imaging just x-rays to rule out any bony injury depending on the type of trauma. But anytime an area of the body is injured with a traumatic injury like that, you know, you go through a painful phase then you might come out of that and you feel okay, but just because you don’t hurt doesn’t mean you’re completely healed. So a lot of times through injury our muscles become inhibited in certain ways. It’s our body’s natural protection mechanism. So even as we come out of that and we feel okay, ensure that you’re completely okay as far as going through, again, screening ensuring that the full pattern is back normally, that it’s the timing of your muscles not just the muscles are strong, but the timing of those muscles are good. That whole reset, reinforce, reload mantra. Sometimes to do that you might need a little bit of rehab help, but in general I think there’s a lot of things that you can get on the wrong side of after a traumatic injury. So just checking those boxes is good.
Cool down theme: Great set everyone! Let’s cool down.
Andrew: For our cool down today we have a fantastic story that came in from one of our TriDot Ambassadors, Seth Wytrwal. Seth posted this story to the I AM TriDot Facebook group and I saw it and gosh it just made me laugh pretty hard. I reached out to him and he was happy to share it to our podcast audience. Basically Seth just really wanted a treadmill and somehow he ended up with not just one, but two basically free treadmills. There’s a lot of twists and a lot of turns to this story. Again, it made me chuckle so I’m excited for you guys to hear it. Take it away Seth.
Seth Wytrwal: Hey TriDot family! My name is Seth Wytrwal and I just wanted to recap a little story that I posted on the Facebook page. So this story basically is how I acquired two free treadmills within the span of a month, but only one is currently working. So keep your eyes and ears out and open for potential opportunities for ways to save money and acquire objects for free or next to free. So November 5th my wife and I were graced with our second child which we are very happy about. Everybody is happy and healthy and home so we’re thankful there. After the first week we had stayed at her parents’ house I was returning to our house with a load of stuff and just around the corner there was a treadmill at the end of someone’s driveway. So I pulled over and asked the gentleman if it was free or for sale and he said it was free. Of course I was shocked and amazed and very happy. So I was able to get it off the roadside, go home, unload the car, come back, pick it up, bring it back to the house, and unload it. Finish up what I need to for the day and go ahead and start to play with it. I plugged it in and in less than three minutes even though it was working perfectly well I was standing on it walking, trying some of the controls, static electric shock fried the system. So now I was out a treadmill. I was kind of bummed, but it still had power to it, but didn’t worked. So that was sitting there and I went back and forth between a local tech waiting for them to come and finally emailed the company proper, but to no avail. They think pretty much the motherboard had died, whatever fuses– I’m not exactly sure. So three weeks after that as I’m coming home from dropping our other son off at daycare, I turn the corner into a neighborhood and there’s a second treadmill sitting on the side of the road in front of someone’s house that had just been rolled out and again, couldn’t believe my eyes. So I pulled over, checked it out, went home, made sure there was room in the car, went back, loaded it up, and got it home. This was a Nordictrack which I was like, “well at least if I need parts I’m probably going to be able to find them fairly easily.” Plugged it in, go to try it out, no safety key. So order a safety key, it shows up that Saturday. Sure enough, universal safety key from Nordictrack, the thing works beautifully. So we’ve been able to use that treadmill. The other one is still in flux as a tech did come by and say yes we needed new parts. So maybe for around 200 dollars we can get the first one fixed which we are very happy about and the likelihood is if it does get working we’ll figure out which one we like better and gift-off or put out on the curb the other machine hoping that someone else can take good fortune. Anyway, I just want to say again, keep your eyes and ears open for potential ways to get equipment for next to nothing and I want to express my sincere gratitude to everyone at TriDot and the TriDot family and coaches for being such helpful people to everything that we do as athletes. Take care. Good luck with your races this year.
Andrew: That’s it for today folks. I want to thank Dr. B.J. Leeper and Coach Jeff Raines for talking about shoulders and the upper quarter of our body with us today. Shoutout to UCAN for partnering with us on today’s episode. Make sure you head to UCAN.co, UCAN.co and use promo code TRIDOT for 10% off your next SuperStarch order. Enjoying the podcast? Have any triathlon questions or topics you want to hear us talk about? Head to tridot.com/podcast and click on submit feedback to let us know what you’re thinking. We’ll have a new show coming your way soon. Until then, Happy Training!
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