Rotator Cuff Pain and Firefighters

Nov. 14, 2006
Pain on movement or sharp pain on lifting can indicate that you have a problem with the rotator cuff muscles, and/or their tendons.

Shoulder Pain in Firefighters

Rotator cuff pain, sprains, and tendonitis appear quite often in firefighters. The job firefighters do requires full range of motion of that ball and socket joint and full function of the muscles around it. Pain on movement or sharp pain on lifting can indicate that you have a problem with the rotator cuff muscles, and/or their tendons. If that is the case, then it would be a good idea for you to see an orthopedist or a very good sports med doc and get it looked at. If they okay it, then you can move on to these exercises. They may have other testing or studies they want you to undergo to rule out more serious problems.

Shoulder Joint Inflammation

The shoulder is an encapsulated joint. Once an inflammatory process starts inside the joint "capsule', the process can be lengthy and painful. In addition to the pain, the mediators of inflammation actually chemically soften the ligaments, tendons and other joint tissues. Thus, activities that challenge those structures can cause more damage than the original injury did.

The supraspinatus, infraspinatus, teres minor and subscapularis are often referred to as the SITS muscles. Each one of these muscles has one end outside of that capsule and one end inside the capsule. The end that is inside the capsule can become very irritated and painful. This pain is a signal that the tendons on the ends of these muscles, and the muscles themselves are more prone to injury at this time. Rest is a good idea at this point. Codman's Arm exercises are indicated here, and your doctor should be able to show them to you. If he or she cannot, Please send me an e-mail.

Because it is an encapsulated joint, the inflammation is tough to flush away. Icing is sometimes not effective (but definitely worth trying). Remember: 20 on, 20 off! Good, deep soft tissue work by an experienced Sports Massage Therapist, Physical Therapist or Chiropractor may help. Ultrasound with both of the above can help even more. Non-steroidal anti-inflammatory meds are often called on too soon, in my opinion. Try the other 3 first: ice, massage and ultrasound. I'd suggest you try Traumeel Ointment. Read more about it HERE. I recommend against Cortisone shots until everything short of surgery has been tried. It can lead to excess scar tissue formation.

Exercises to avoid (See Picture #1)

I do a lot of sports injury rehab work, which entails a lot of shoulder injury work. When someone comes to me, and says they hurt their shoulder working out, I ask what their upper body workout consists of.

All of them do at least one of these exercises:

  1. Behind the neck military press
  2. Behind the neck lat pull downs
  3. Straight bar bench press

This is what I tell them: "Any time you put your shoulder joint in a position that twists the shoulder joint capsule (extreme internal or external rotation, as in all 3 of those exercises) you are ringing it out like a sponge. Then, if you add a load, such as pushing or pulling, you are asking for trouble."

The usual response to my comment, "Yes, Doc, but I feel it here when I do that, and I never get that feeling with any other exercise!" My answer, "That feeling you get is the tearing up of your shoulder joint. You don't want that feeling! Even if you don't have a big injury now, you will! Stop doing those exercises!"

Substitute (respectively): if you know them...

  1. Back flies or upright rows for posterior delts
  2. Swimmer pulls with tricep push down pulley machine (straight armed) for teres/lats
  3. Dumbbell presses and pec flies in a safe range of motion for pecs
Your shoulders will thank you.

I would also train very carefully with your shoulders in the future, no matter who you are. Low back and shoulder injuries are common in Firefighters. Train the rotator cuff muscles specifically with light weight as a warm up on your chest and shoulder days at the gym. (The SITS muscles: supraspinatus, Infraspinatous, subscapularis, and teres minor). There are specific exercises for each. You should protect your future with just a few extra minutes each workout. Below, I will show those exercises!

Balance your workout:
For the most part, remember that people tend to train their push muscles more than their pull muscles. They over-train chest/pecs, and don't do as much lats/rhomboids. This leads to overly short muscles on the front, and internal rotation of the shoulder joint. Posture changes, to a forward lean... and palms face back when standing straight up. (The palms should face in). Try to do equal reps, sets, and weights with the front of your body as you do your back of body. It might take a while to even out!

Rotator Cuff Strengthening:
Warning!: If anything listed below hurts you, stop! Try lowering your weight. If it still hurts, then or after, ice it for 20 minutes, and write me. These are small muscles, with very specific actions. Be precise with your form. Form is everything here, weight is nothing.

Here are the exercises I would recommend:

Supraspinatus/Empty can (See Picture #2):
Weight: 3-10 lb. dumbbell. Don't push this- it's a tiny muscle. I use 5.
Reps: 2 sets of 12
Form: Stand with a dumbbell in each hand. Do one arm at a time. Raise your stiff arm in front, up away from your body to shoulder height, no further. Rotate the hand inward until you are in a thumb down position. In that thumb down position, lower the weight until your thumb hits your thigh. Raise it, never above the shoulder level. Move slowly. Note Picture #2, in the picture on the right, the shoulder is down and away from the ear. That is correct form. In the picture on the left, the shoulder is "scrunched" up to the ear. That's not correct.
Do 12 reps. Do the other arm, and repeat both.

Subscapularis (See Picture #3):
Weight: 10-40 lbs. Form is important here, so try it light first. I do 30 lbs. with a "healthy" shoulder.
Reps: 2 sets of 12
Machine: Set a cable pulley machine so the handle is at shoulder level. Use a D ring handle.
Form: Your back is to the machine. Grab the handle with a stiff arm. Raise the stiff arm out in front of you. The cable should run under your arm pit. The arm should be in the up position of the previous exercise, only palm down. Elbow locked, hand out at shoulder level. Hold your body and trunk stiff. Now translate ONLY your shoulder forward. Of course the arm and hand will move to, but it's just a shift forward, leaving the rest of your body still. Don't rotate your trunk. Your scapula will track along your ribcage, and your humeral head will push forward. You should feel this only lightly in under your armpit, actually in the front (anterior) surface of your scapula (shoulder blade).

External rotators - teres minor and infraspinatus (See Picture #4):
Note: This is described and shown in the picture below for the left shoulder, but you should do all of these on both shoulders. You can then do the same thing on the other shoulder. Weight: 5-10 lbs. I use 15 when my shoulder feels good, less when it doesn't.
Reps: 2 sets of 12. Do Right arm, then left, and repeat.
Machine: Set cable pulley machine so the pulley and handle is at elbow height. Set your weight. This exercise can irritate, so better to err on the light side then the heavy. Use a D ring handle.
Form: Stand with your right shoulder to the machine, your left shoulder away. Hold the handle in your left hand with palm facing the machine, elbow bent to 90 degrees. Glue your elbow to your ribcage. Keep your shoulder down and away from your ear. The inside of your forearm should be on your belly to start with. Move away from the machine until the slack is taken out of the cable. Now externally rotate your left upper arm, lifting the weight until your knuckles point straight ahead, now go a little further. Don't force it into external rotation, it will hurt you. Lower the weight. Do 12 and go do the other arm, and repeat both.

Internal Rotators - pec. minor and subscapularis (See Picture # 5):
Note: This too is described for the right shoulder. You should do all of these on both shoulders also. But, this is only going to be described this way.
Reps: 2 sets of 12
Weight: internal rotators are stronger and less vulnerable than externals, so I go a little heavier... 20-30 lbs. for a guy... I use 20 when I feel good, and less when I don't. Know yourself.
Machine: Leave machine in the same position as last exercise. Turn around so your right shoulder is to the machine. Glue your elbow to your ribcage. Keep your shoulder down away from your ear. Bend your elbow to 90 degrees, knuckles pointing forward, and palm facing away from the machine. Step away from the machine to take the slack out of the cable. Rotate upper arm in to lift weight until the inside of the forearm is on your belly. Return the weight to almost touching the stack. Again, do not allow external rotation to the point of discomfort. Repeat 12 times. Do the other arm. Do both again.

Read this again, sitting in front of the computer, do the exercises in the air. Do it a couple of times. Then when you go to the gym, you should be able to duplicate them. Does this make sense? I hope it helps.

This is a great warm up before any upper body workout. It takes only 3-5 minutes once you get the hang of it, and it can save you problems later. IF, however, you already have a problem, try to get help from a good physical therapist or orthopedist and an okay before you go at this. You could even go as far as to print this out for them and ask if it's okay for you.

Coming Soon:
Shoulder Relief by Dr. Jen: a 45 minute comprehensive shoulder-safe workout to strengthen and prevent injuries to the shoulder!

Dr. Jen Milus, DC

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