Sports Essentials | Preventing Overhead Shoulder Injuries with Adam Kimberly PT, DPT, OCS

Podcast Transcript

John Horton:

Welcome to Sports Essentials, a sweatier version of our popular Health Essentials Podcast. I'm John Horton, your co-host, with Dr. Lauren Wichman.

Dr. Lauren Wichman:

Hi, John. Great to chat with you as always. I'm super excited for our upcoming episode today.

John Horton:

Well, I mean, you should be because it sounds like this is something that you deal with all the time, because we're here to talk about overhead shoulder injuries. I know when we were talking the other day, you said almost every single patient you saw that day had something wrong with their shoulder.

Dr. Lauren Wichman:

It's definitely one of the most common things I see in my office. Shoulders are a joint that goes through a lot, is put through a lot, whether you're somebody who plays an overhead sport or are working in the yard. I think that there is a lot that can be involved here that is relevant to everybody and why we wanted to make sure that we addressed it today.

John Horton:

Yeah. And it sounds like there are some really simple things that we can do to keep our shoulder strong and just kind of ready for everything that we put it through.

Dr. Lauren Wichman:

And that's why I think our guest today, Dr. Adam Kimberly, is going to be phenomenal in walking through a lot of the aspects that can be helpful for not only treatment when something is not functioning the way it should, but also prevention going forward, because this is something that is so common.

John Horton:

Well, given how many people are dealing with this, I think we should get right to it.

Welcome to the podcast, Dr. Kimberly. I got to tell you, we are so happy that we were able to steal a little bit of time from you today and kind of get you out of that PT room.

Dr. Adam Kimberly:

Happy to be here. We really appreciate the invite and just looking forward to a fun conversation.

John Horton:

So I have to tell you, I've spent some time with PTs over the years. I ding enough stuff up when I'm out doing things. And I got to say, I'm always amazed at how they're able to just really narrow down what's wrong. You guys are almost like body-part detectives in the way you go about that and kind of solve the mystery as to what's going on. You've got to feel like a little bit of a sleuth as you're doing this.

Dr. Adam Kimberly:

Yeah, it's a fun job because of that. PTs are kind of the friends that nobody wants to have. It's fun to know them when you need them, but you don't want to have to know them because that means you've usually had something hurt, you've been through something that you don't want to be going through. But that's kind of what drew me to the profession in general, is like it's kind of a sleuthy nature to it, is you have a few things going on and you have to start to draw the dots and you have to start to try and kind of connect everything that's going on.

Dr. Wichman, same kind of thing as a sports ortho doc. I mean, she sees some crazy, if not crazier stuff on the day-to-day, and then she sends them our way when, hopefully, we can help out along the way, too. So yeah, it's fun.

Dr. Lauren Wichman:

I was going to say, you call yourself the friend that nobody wants to have. But I would say that you are, from a sports medicine doc perspective, you're one of our best friends in terms of getting people feeling better on a day-to-day basis, and kind of working together to be able to achieve that is awesome. It's like one of the best parts of my job.

Dr. Adam Kimberly:

Yeah, no, it's great to have a back and forth with sports ortho docs who believe wholeheartedly in what we do. Because I mean, I think we all help each other out and we all make each other better and, ideally, make the patients better as fast as possible, which is great.

John Horton:

Well, let's talk a little bit about what you do when somebody comes in with a bad wing. Because we're here to talk about shoulders. And particularly, all these overhead shoulder injuries that we seem to be seeing more of. So to kind of get started here, let's spend a little bit of time just talking about the shoulder itself, which is just such a complex joint. Is that kind of, I guess, the start of why people experience so many problems, Dr. Kimberly?

Dr. Adam Kimberly:

So I mean, yeah, you hit the nail on the head. It's a complex joint. It has what we call six degrees of freedom. So it moves in six different planes. And because of that, because it has all that great motion, it needs a lot of stability and a lot of things to help stabilize it. Which is hard. I mean, we have ... the analogy I like is, our shoulder joint is almost like a golf ball on a tee. But the golf ball and the tee both move. So because of that, we have all that crazy mobility within it. We need ligaments, we have tendons, we have muscles that all help support it and keep it in place. And if something's not working well or if something's overworking and overcompensating for other parts of it, then it sets it up for injury. And it has ... sometimes, you just need a little guidance and to help it heal or help it recover. And that's where we step in.

Dr. Lauren Wichman:

And I think there are a couple structures, a couple pieces and parts, to the very complex shoulder that I see probably relatively more frequently in my office, and then end up sending Adam's way when it comes to taking care of patients. I think a lot of people have heard of the rotator cuff before, and we don't actually really necessarily know what it is. But really, the rotator cuff is for muscles that work together, just like Adam said, to move that golf ball on the golf tee to be able to allow the shoulder to do what it does.

John Horton:

I have to say, when I've looked at some of the drawings of how the shoulder is put together in prepping for this, it looks like a plate of spaghetti in there. Like you said, with all those tendons and muscles and everything running around, you can see how easily it is for something to just get a little bit off.

Dr. Adam Kimberly:

Yeah, for sure. And I mean, for those anatomy nerds out there like myself, there's another analogy that I really like. The way our eye is set up with the eye muscles is actually very similar to the way our shoulder is set up with the muscles that surround that. And so-

John Horton:

…really?

Dr. Adam Kimberly:

...you think about that, if a muscle wasn't working — it really is, if you look at the kind of anatomical comparisons.

And so if you had a muscle not working well in your eye, you'd be very aware of it and you'd want to have that addressed right away because you wouldn't be seeing things clearly and you wouldn't look normal. But something happens in our shoulder where it's not working appropriately and we can ignore it for a period of time because we can get along well enough without it. But then, we push that down the road and it turns into something significant.

Dr. Lauren Wichman:

And I think when it comes to just injuries that happen over time, the rotator cuff is definitely something that, just like Adam said, the muscles and the tendon that make up that whole rotator cuff structure, it's probably one of the most common things that can become irritated or inflamed.

But to your point, John, the number of other structures we have — we've got the bones, we've got the cartilage, that kind of smooth surface that covers the bones and allows them to move. We've got the labrum, which I refer to as kind of the suction cup that surrounds that golf tee and keeps the golf ball and the golf tee together the best way we can. So there's a lot of different things that people hear that can be pieces to this puzzle.

John Horton:

And I'm always amazed. I mean, your shoulders just take a beating. I mean, if you think about how much you use them during the day and everyday life, I mean, that's a lot in and of itself. And then, obviously, on this show, we're talking to a lot of athletes. You can really see where it becomes a big deal just because of the amount of use that you have. What sports do we typically see a lot of shoulder issues coming out of?

Dr. Adam Kimberly:

Yeah. I mean, anyone, we're using your arm. But I mean, that is the cheap answer. But really, I mean, any overhead repetitive sport. So we're talking baseball, we're talking volleyball, we're talking tennis, we're talking pickleball, swimming. I mean, they all just ... they use your arm in a repetitive manner overhead frequently. And those are just like what we consider the sports.

Then. we also have the people training for those sports who are doing weightlifting, who are doing cardio work, who are doing new high-intensity interval workouts that they maybe haven't done before where they're using their arms in an overhead manner where they may not be ready for or they haven't trained in a long time. And that can set them up for injury, too. I don't want to say any and everything, but it's a little bit of the answer. Just because humans find the ability to hurt themselves in myriad of ways. And so we try and kind of get them back to doing whatever they want to do.

Dr. Lauren Wichman:

And I think Adam, you obviously have a very specialized set of skills when it comes to the shoulder with your role helping out, taking care of Cleveland Guardians. And taking care of the guys that are throwing 90 miles an hour, which is probably some of the most stress you could even think of on that joint.

Dr. Adam Kimberly:

For sure. I mean, we talked about a little bit before. The most ideal way to hurt a shoulder is throwing a baseball really hard overhand. And it's because, like you said, we have so much dynamic mobility and we have those bony parts that surround it. So especially, on the top, the roof of our shoulder is called our acromion process. We have a tendon that runs right underneath that. With repetitive overhead motion, sometimes we can get that tendon irritated or scuffed up. And that can cause a lot of issues and pain. That's why baseball pitchers are usually hurt more readily than softball pitchers because they have that overhand motion, which doesn't cause the same kind of trauma.

But I mean, that's again, the nature of the beast. And we got to figure out the way to make them function, way to make them be as successful as they can so they can do what they love.

John Horton:

Yeah. Those rotator cuff issues have ruined many a season for a lot of teams. And I know, when you see a video of a pitcher throwing a ball, the amount of stress that it looks like is on their shoulder is just amazing. So when you see these injuries, is this just a case of you only have so many throws in there? Or is it just, you consistently wear it down, wear it down, wear it down, and eventually one day, it just kind of goes?

Dr. Adam Kimberly:

It's an interesting thing. Each human is different, right? We each have a different level of capacity with how our body's made up. So collagen and elastin are two things that make up our tendons and ligaments, like what the percentages are there. That's what allows some people to pitch into their 40s and 50s. That's what makes some people flame out in their late teens, early 20s. It's so different there.

But then, you also pile on postural changes, strength changes, how they take care of themselves, how they prep for games, how they cool down after games. There's a lot of things that go into it, and preparation is one of the best things that we can give people to prevent these injuries from turning, from taking a nasty turn, right? So if we can help them develop a good plan to be as healthy as they can before they start to throw, and developing those things in the early season, then they can hopefully have a healthy season and have a healthy career. But it takes work to get to that point. You can't just walk out, pick up a ball and start throwing in games. It takes time to get there.

Dr. Lauren Wichman:

Yeah. I think you nailed it with the combination of volume and mechanics, that's huge when we're talking to a lot of our baseball guys. But then I think to your point earlier, too, Adam, of this applies to everybody. Volume and mechanics when it comes to a volleyball serve, volume and mechanics when it comes to somebody who's taking up pickleball, and anything and everything in between. I think that really, really can make a big difference on sustainability and performance going forward.

John Horton:

We're going to get into some of that proper movement. The proper movement is a medicine, as Dr. Wichman likes to say, a little bit later. But before we get there, let's talk a little bit about the diagnostics that take place. I think a lot of us have had an achy shoulder from time to time. When are we crossing that line to it just being a little bit sore, a little bit achy to when there's a problem? And how do you determine that? I guess maybe Dr. Wichman, let's start with you. Because I think you see people first when they come in and they're like, "Something's just not right."

Dr. Lauren Wichman:

If one of my athletes is coming in with some shoulder pain, many times, they actually approach their athletic trainer first. So that good communication between an athletic trainer saying, "Hey, this may be coming in, coming in your way, this is the story," is super helpful. And then, they come in my door. And usually that involves, No. 1, getting an X-ray first and foremost to see what that golf ball, golf tee ball and socket looks like is really, really helpful baseline information.

And then from there, I talk to them, I try to kind of get the story in a way. And do some diagnostic special tests to figure out where do I think the pain may be coming from. And once I have a sense of, OK, this could be the pain generator here with some other secondary factors, that's when, many times, I'm reaching out to Adam to say, "Hey, this is so-and-so, can you fix them?" And they head over to him.

John Horton:

And then, Dr. Kimberly, it sounds like you basically end up giving that second opinion and doing some of your own tests and doing your own kind of diagnostics.

Dr. Adam Kimberly:

Yeah. Yeah. And it's great having information from Dr. Wichman or whoever our referral source is, like what they saw first. Because that helps us rule out a lot of things. And then, we can kind of travel down into more of the nitty-gritty, depending on what we have.

And so we'll look at range of motion. So literally how far that shoulder is moving in a bunch of different planes and compare it to their other side. But also compare it to normal ranges that we know based off of years and years of research.

And then also look at strength. So how well each one of those rotator cuff muscles and the other surrounding shoulder muscles are able to turn on. And are they strong? Are they strong and painful? Are they weak? Are they weak and painful? And that tells us different things about what's going on within the shoulder and it helps us start to navigate a rehab plan.

Then, we also have other kinds of positions and testing movements where we can test out those other non-contractile tissues, as we call them, the tissues that don't shorten actively, like muscles. So like our ligaments or our capsule, which is kind of like the water balloon that surrounds everything and keeps the joint fluid and it keeps everything in space. So we can test ... and the labrum, like Dr. Wichman said earlier. We can test all those different things to try and determine what is irritated, what's not working well. What we can start to strengthen to take pressure off that irritated thing and to help get everything moving well again.

John Horton:

I've gone in for a shoulder PT session at times, and I know I was amazed when you get in there and they start doing those special tests where you hold your arm out and the PT would apply pressure and be like, "Push against me and do this." And I don't know how many motions there were, but they'd find that one where it was like you couldn't do anything. And they're like, "Well, that's your problem. It's this exact spot."

I mean, is it really that defined when you're doing these tests that you can narrow it down to one little band or strand in there that's just not quite right?

Dr. Adam Kimberly:

Sometimes yes, sometimes no.

Dr. Lauren Wichman:

Yeah.

Dr. Adam Kimberly:

Ideally, yeah, we can find that and that can kind of help us target treatments. Because sometimes, if we find that and Dr. Wichman can place an injection perfectly or we can start them on the right medication, we can get that one thing quieted down and then we can strengthen up everything else, great. Oftentimes, it's a whole myriad of other things that are going on at once, and we have to kind of treat each thing at a time, figuring out what's the most provocative, and then kind of going our way down that path to try and make everything work as well as it can together.

Dr. Lauren Wichman:

And I think a lot of times, too, when pain is centered in one area, it causes our motion as a whole to become a little bit dysfunctional. In which case, that shuts down other muscles that aren't supposed to be shut down and are supposed to be activating in addition to that.

So I think that's where Adam's exactly right. We can sometimes treat one thing that we think may be the primary source. But then, that's where Adam can be so helpful, too. And all the other things that kind of fell apart while this one specific structure in the shoulder was giving us problems, he gets everything else working in tip-top shape.

Dr. Adam Kimberly:

Yeah, because it's pretty rare that someone will come in, have one injury, see the doctor the next day, see me the next day. It's usually the shoulder's hurting for a little while, they cheat around it so they start to develop other movement patterns that makes other stuff hurt. They finally decide they want to go see the doc, they see the doc. Then, it may take a week or two to come in to see me and all of a sudden they've developed all these, what we call compensatory patterns.

Because we're smart, like humans figure out ways to do it. Even though it may not be the best thing for them, they figure out a way to make it work. And so now, they've developed all these weird patterns, their shoulder blades moving in a strange pattern, their ribcage isn't moving well. So we have to kind of walk back, figure out all those things, get them moving in the right way, hopefully, to then start to develop good patterns and get back to doing what they want to do without pain.

John Horton:

Speaking to that, I mean, do you find that athletes tend to just, to wait a little too long to get a shoulder looked at?

Dr. Adam Kimberly:

It depends on the location, right? So if we're working with our pro guys, we're lucky because we have a bunch of people looking at them all the time. So if someone's starting to move a little bit differently or we notice velocity changing or we notice any little thing, we have a whole group of medical staff that's like hawk-eyeing that guy. If you have a-

John Horton:

…a big investment.

Dr. Adam Kimberly:

…right. If you have a little leaguer or a high schooler who's new to sports or they're getting into it or they're scared that they're going to be asked not to play or they're going to miss time and so they may cheat around something a little bit longer thinking that it's going to get better or not necessarily knowing who to go to. That's why it's nice, I mean, the Cleveland Clinic, we have nice relationships with a lot of the schools. We have athletic trainers embedded in the schools who can be there and be helpful. But most people will probably wait longer than what they should to get something checked out when we can catch it as a small thing and hopefully fix it faster. But it usually turns into a big thing and then we got to figure it out.

Dr. Lauren Wichman:

Totally. And I think the reality is is that when you're putting your arm through the stress that is required for a sport like baseball, or for somebody who maybe has taken up pickleball, is now fully invested and is doing it five days a week, that new stress on that shoulder is going to result in some aches and pains. And some level of that is expected. But when that persists, when just like Adam said with our guys, if velo starts dropping, that's a concern. And we emphasize that we are more than happy to take a step, evaluate this, and then collaborate to come up with the best way to get you back on track.

John Horton:

Are there simple tests that somebody can do at home just to kind of go ... to see whether their shoulder maybe has a bigger problem or whether it's just soreness? I know Dr. Kimberly, you had mentioned the kind of range of motion. Is there some sort of thing you can do just to kind of test it yourself and look and go, "OK, this arm seems way off."

Dr. Adam Kimberly:

Yeah, I mean, the kind of quick and dirty way is literally stand in front of a mirror, take both of your arms up overhead. If you have one that moves up great and one that's only coming up this high and it hurts, it's probably a sign that something needs to be addressed. Or you can try and reach behind your back like you're trying to scratch your back if you can only get so high with on versus the other, that's ... there's usually going to be some asymmetry side to side just based on handedness. But if it's a big thing where you're only getting to your back pocket on one and you're getting up to your mid-back with the other one, that may be concerning. And again, if it's painful.

I don't know, what do you have, Dr. Wichman?

Dr. Lauren Wichman:

I totally agree with that. I think honestly, too, I hear more people that are noticing with even just simple day-to-day type activities. Like, oh ... kind of like what Adam was saying in terms of like, "Oh, I'm reaching up to the top shelf, but I can't get there with this other hand." Or I think usually the straw that breaks the camel's back is when it wakes them up at night. They can keep up with the pain until it starts waking them up and that is the final thing they're willing to put up with.

Dr. Adam Kimberly:

Yeah, that's a great — and that actually reminds me of a story. So it was one of the first patients I saw when I was on clinicals in PT school. And he was a gentleman, probably in his 50s, and he was unable to put his wallet in his back pocket with his right arm. So he just kept on going, started using his left arm. It wasn't until he couldn't ... he then developed an issue with his left shoulder, it wasn't until he couldn't put his wallet in his back pocket with either arm that he waited until to go to see the doctor. That's concerning, right? You got to go in a little bit ... like figure it out, go see someone earlier. Then, we can get you on the right path to healing.

John Horton:

And here's one thing I want to bring up here, and we talked about this in our pre-chat, is that most of these sorts of shoulder injuries, it sounds like, can be addressed through PT. And I don't know if a lot of people kind of hold off because they're worried they're going to need some sort of surgery or something really extreme. It sounds like you're able to address a lot of these issues just through a good physical therapy regimen.

Dr. Adam Kimberly:

Yeah, ideally that's the case. Most folks just need to, A, take a little time off. Take some time off from the irritating thing. So if that doesn't mean you're not doing anything, it just means that you're taking some time off from the thing that is causing that shoulder to hurt immediately. And that's hopefully where we can help out with a prescriptive exercise program to help you strengthen up the stuff that can take some pressure off the irritated process and get you back to being active within your tolerable level. Because like I said, movement is exercise, motion is lotion. What you can do to help get things moving, helps tissue heal as well while you're allowing that irritated tissue to recover.

And then also, figuring out what we can do to develop that exercise plan. And develop things that you can do on a daily basis to make your shoulder feel better, strengthen up the things that need to be strengthened. Generally, we can get around having to have surgery or having to have anything major done because like we mentioned, with all the stuff that's going on within the shoulder, there's a lot of what we call redundancy built in. So there's other muscles that can help if one specific muscle is irritated.

So we can kind of cheat around it in a good way for a little bit of time while we're allowing that tissue to recover and you'll go about your life. It's very rare that one of these things will lead to surgery right away, outside of like a majorly traumatic event where the shoulder was dislocated or a major rupture happened. These kinds of chronic wear and tear things usually will get better with a focus program, as long as we kind of stop doing the thing that's hurting for a little bit.

Dr. Lauren Wichman:

And I usually talk to patients that kind of like ... our treatment options are kind of on a spectrum in a way. Surgery is kind of on the one extreme end. But most patients prefer to start on the total opposite end, which is using movement as medicine and working with our physical therapy colleagues to be able to work on strengthening and activating the muscles that we need to be able to bounce back. And if we combine that with a little bit of anti-inflammatory, regular medicine, like many, many, many, many times, that takes care of everything.

John Horton:

And Dr. Kimberly, I love what you said about just how there's so much going on there and you have some parts that might compensate for others. Because it sounds like there's a reality that probably none of us have a shoulder that is a hundred percent. I mean, we all have something in there that probably has a little tear or isn't quite right. But the whole operation kind of compensates for it and allows you to keep putting things on that top shelf or throwing a ball or whatever it is that you're doing.

Dr. Adam Kimberly:

Right, for sure. There's some research out there, it says essentially, 40% of women over the age of 40 are going to have some level of rotator cuff tear. And that's with or without pain. That's just humans over 40, chances are, there'll be some kind of tear going on.

And that doesn't mean it's a full thickness there. It doesn't mean the muscle's completely ruptured. But if you looked in there with an MRI, you'd probably see some fraying, you'd probably see some tissue irritation. That doesn't mean anything needs to be done. That's why a lot of times, patients will want to jump to an MRI, they just want to know what's going on. Well, even though we have that MRI, that doesn't necessarily mean we know what's going on and we know what you 100% need. We want to try and figure out what we can do from a least invasive process first. So if we can focus on exercise, if we can focus on us in physical therapy, getting our hands on you and kind of feeling how things move, stretching out the right things, getting the right exercises going, then we can take pressure off.

I've had patients who have had full-thickness rotator cuff tears go back to living normal lives. Yeah, they may not be throwing a baseball 90 miles an hour, but they can go on and live the life that they want to live, do most of their things without irritation or without provocation. It just depends on where they are, how we're able to get them there and what their expectations are.

Dr. Lauren Wichman:

I think that's where, just like you said, in terms of not necessarily jumping right to needing that MRI, sometimes, it can even be more confusing than not. Because people have had maybe a partial tear to their rotator cuff for years, long before this pain even started. And it muddies the water a little bit to thinking that, "Oh, this won't heal unless we go in and fix that." Not really true all that often.

Dr. Adam Kimberly:

And part of the problem, too, is, I think the wording that we, as the medical world use, too, it's like, "Oh, you have a tear in there." Or, "You have a ruptured X, Y or Z." It sounds awful and it sounds like something that needs to be fixed right away, but it's not. It's all about how we frame it and how we describe it to the patient.

Because pristine cartilage, tendon, ligaments, bone is pretty stinking rare. Like you said, almost no one has a great-looking shoulder, just like no one has a great-looking back. There's a lot going on, a lot of stress that happens against life against gravity for decades of time. So just knowing that if we can get you moving in a comfortable way, you can go back to being completely normal again. It just takes a little bit of time sometimes.

Dr. Lauren Wichman:

Especially in our overhand athletes, no doubt about it. They have some wear and tear.

Dr. Adam Kimberly:

Right.

John Horton:

Well, for those of us with wear and tear, and I'm pretty confident I'm in that group, I'm a little north of 50 and I think I would be in the dinged and dented aisle at the store. So what can we do? How can we do that proper movement as medicine to start strengthening that shoulder up and maybe take care of some of these issues?

Dr. Adam Kimberly:

Yeah, great question. I think a lot of it is preventive stuff, right? So A, if you are having pain, think about what you're doing that's causing those symptoms. Maybe taking a little bit of time off from that, but trying to continue an exercise program that isn't causing you pain in real time, just to keep everything moving, can be great.

Posture plays a huge role in how our shoulder works. Everything about us as humans wants to be pulled forward, OK? Gravity, our eyes are in the front, mouth is in the front, nose in the front, everything about that wants us to come forward. The more forward we come, the more forward our shoulder becomes and the tighter everything can kind of work. I mean, you can try that yourself. If you sit forward and try and lift your arm, it goes much less high than if you sit up tall and try and lift your arm up. It's just how it works.

So paying attention to your posture throughout the day, if you have to work on a computer, if you have to work on a laptop for extended periods of time. Take a break every 20 minutes or so, try and sit up straight, do a few, what we call shoulder squeezes. Literally just trying to squeeze your shoulder blades back in together, work on helping that posture. Because that just puts the shoulder in a better spot to be able to function.

In that same vein, everyone has a doorway in their house. You can get in a doorway, you can do, what we call a peck stretch. So arms just resting on the side of the doorway, you lean forward without dumping your head forward, just lean forward to feel a stretch across the front of your shoulders. It's a nice way — holding that for 20, 30 seconds, take a few deep breaths — helps open up that area, helps get things moving a little bit more and taking some pressure off that shoulder.

Another one that I really like, just to kind of help get everything turning on in a fairly comfortable way, is you get in quadruped position and they do an exercise called cat, cow or cat, camel. So literally you're arching your back like an angry cat and then you're letting your back come down and your shoulder blades come back together. You can do about 10 of those. Again, it gets our ribcage moving, it gets our thoracic spine moving. Which is the part of our spine below our neck and above our lower back, where all of our ribs attach. Which is really important for motion. And it gets our shoulder blades moving around that ribcage, which is another important factor in helping our shoulder move freely and move healthily.

I mean, kind of three fairly easy ones that anyone can do anywhere to kind of help get the right muscles turning on. And put the shoulder in as helpful of a position as possible to take pressure off the irritated stuff.

John Horton:

And that quadruped would be on your hands and knees, right? You kind of get on-

Dr. Adam Kimberly:

…yep.

John Horton:

...the floor like that. Almost like you're making a little bridge and then just kind of put that back up a little.

Dr. Adam Kimberly:

Exactly. Yeah. And if you don't want to get on your floor, you could do it on your bed, you can do it on the couch. I mean, whatever. You're just on your hands, on your knees. I'll even have patients who, if they don't want to get down like that, they'll just put their hands on a chair or put their hands on a table and do the same kind of thing. So you're arching your back and letting it fall back down, breathing as you're doing it, just helping that shoulder blade and shoulder move around that ribcage. Getting some things unstuck and also helping to turn on some of our muscles that turn on when we are loaded through our arm.

John Horton:

When you talk about posture, as we sit all day, like you said, I think we do naturally slouch. Every time I have one of these discussions, I always find, as soon as you bring it up, I sit up a little straighter and put my shoulders back. I do the same thing when I talk with our chiropractor, Dr. Bang, he's on for a lot of Health Essentials Podcasts. But it's hard to think that just kind of sagging forward a little bit, maybe drooping your shoulders, that it does that much maybe to the musculature in there and throws it off. But just I guess being in that position for hours, does it just kind of kink everything up in there?

Dr. Adam Kimberly:

Yeah. I mean, our tissues respond to forces that are placed upon them. So it's not like a car in that a metal part will always be the same size. It won't really change unless a major stress is put upon it. Our tissue responds to positions we put it in. So if I'm sitting forward for long periods of time, the muscles in the front, my pec muscles, will tighten down a little bit. The muscles in the back and around my shoulder blades will stretch out a little bit more and probably become a little bit weaker because they're not working as well as what they could.

So then, if we're in that position for long periods of time, sometimes, years for folks, and we try and get them out of it, it can be hard. Because their body hasn't been in that position and literally, the tissue has shortened down to where they're kind of stuck there. That's an extreme case. And I don't want to use those kinds of words to scare people out of it. But by just keeping those ranges fresh, by getting into better positions periodically, squeezing those shoulder blades back, moving, turning on the muscles between their shoulder blades and around the back of their shoulder. It helps to, A, freshen up that posture, get them stronger in that neutral position and you just look better. People look better standing up taller than they do slouching forward. I mean, it just helps in a myriad of things.

Dr. Lauren Wichman:

I think everything that you've been saying is relevant to so many different people. Whether you're somebody who works at a computer all day in a desk type job or you're a student who's hovered over a desk. Or all of us that are on our phones casually turning, lowering those shoulders in and in. I think everybody can be guilty of at least putting ourselves in this position in some way, shape or form.

Dr. Adam Kimberly:

Yeah. It shouldn't be a punitive thing, everyone does it. I'm as culpable as anyone out there. I can find myself in those bad postures. But it's just like setting yourself a soft reminder. It's like, “OK, I need to sit up tall.” Not being mad, not being upset at yourself. But just being like, "OK, let's sit up tall. Let's do a few shoulder squeezes. Let's just kind of relax into a better posture and get out of it."

Because it's just those small reminders time after time after time that's going to help you, as opposed to just being mad at yourself or getting frustrated and saying, "It's never going to work. This is just who I am." Just doing little things throughout the day help, to build over time. Because as we were talking about before, most shoulder injuries are chronic things. It's rare that it's that one-time insult. Usually, little things happen over time that help build to this issue that then kind of hits the threshold to the point where you can't do things anymore.

So same kind of thought process. By doing little corrective exercises periodically throughout the day, hopefully, we can keep you in better shape to prevent you from getting to that point.

John Horton:

So just keep moving those shoulders around. So do those little stretches you said. Sounds like just ... I mean, if you're sitting at your desk just reaching up and stretching, is that enough just to keep those shoulder muscles kind of engaged a little bit and to keep that slouching from happening?

Dr. Adam Kimberly:

Sure. As long as it doesn't hurt. So I mean, by reaching up overhead, a nice stretch there, reaching behind your back, kind of clasping your hands behind your back and trying to lift your arms back behind you can be a nice way to stretch out the front of the shoulder in front of those chest muscles as well.

And then, working on a nice strengthening program, focusing on the rotator cuff, focusing on those muscles around the shoulder blade, easy things that you can do around the house, is always a great place to go. Usually, one of the hard things in the physical therapy world is giving someone an exercise program and then figuring out what it looks like for the rest of their life. We have all these sheets, we have all these exercises, things that we'll give patients and then they'll walk out the last days like, "So do I just do these forever?" And it's like, well, not necessarily. But we want to figure out little things that you can potentially do throughout your day and/or throughout your week to make it stay healthy and feel as good as possible without having to do something every hour on the hour for the rest of your life.

Dr. Lauren Wichman:

I think that is a hugely important point. I think a lot of times when ... for example, with our baseball guys, right? They have a very regimented arm care program that is extremely necessary to be able to keep up the health of their throwing arm. And that's what I try to tell a lot of the patients that walk into my office, who I am sending over to PT to be able to talk with all of you guys. And I tell them that working with you guys on an individual basis is so helpful. Because they will not only find the areas that have a little bit of dysfunction, but also teach you ways that you can keep that at bay going forward.

If you're going to continue playing your sport, and this has happened once, it can very well easily happen again unless we do something about it. So I even offer, too, I'm like, "Hey, when they give you your program, talk about it." It might be something that you do even before you go out, right? Before you're going to go play pickleball, these are the three things that you do for warm-up to make sure that your posture looks good, to make sure that everything's warmed up and ready to go for your day of playing going forward.

Dr. Adam Kimberly:

No, that's perfect. You put it really, really well. Because our connective tissue, too, it's kind of like Silly Putty®, if you think about it that way. And as we get older, it's the more kind of stiff, rigid, silly putty that takes a really long time for you to work into it and make it pliable and make it soft to where it can stretch out easy.

Whereas, if you go hard really, really fast, it's not going to respond as well as what we want it to. So by doing those little exercises, by doing those little things early, you help to kind of freshen up that tissue, you help draw in good blood supply, you help make it a little more pliable, to then make things feel better as you're doing them.

I can tell you, I don't feel as good rolling out of bed as I used to. I mean, it takes me a few steps, 10, 15 minutes before I start to feel a little more limber. It's just different from what it used to be. So by doing those little preventive exercises early on, and then maybe a cool-down set of something to help put you in a better place to where you can kind of quiet down and then go live the rest of your day. It's a good place to be and it doesn't have to be a super long program. Sometimes, it's just a few exercises before and after that puts you in the right place.

John Horton:

Now, you had mentioned strengthening. And I know a lot of people, people lift, that's a big thing. And we haven't really talked about that during this, but I know when we talked earlier, you said so many shoulder injuries are coming from people working out in the gym. How careful do you have to be then when you start trying to do these strengthening exercises to make sure that you're basically not just re-injuring yourself or making a situation worse?

Dr. Adam Kimberly:

Yeah, good question. And we talked about this a little bit in our pre-planning. Every time I've hurt myself, my shoulders specifically, it's been from weightlifting exercises. Just because, I mean, especially in high school and college, I mean, I was an ego lifter just like everyone else. I wanted big numbers and I wanted things to look good.

John Horton:

A couple extra plates on there, right?

Dr. Adam Kimberly:

Yeah, right. It's what got the job done.

But in doing that, I kind of figured out what was right and what wasn't right for me. And I mean, hopefully I've gotten smarter in my older age, but I'm not sure. But having a well-rounded exercise program is important. So not benching every day of the week.

Again, we're humans. Everything about us is in front of us. We're very prone to working out the things that we can see. So we like to do chest, we like to do shoulders, we like to do abs. All of those things work one side of our joint, where we have the whole other backside that doesn't always get a lot of work. So making sure that you do back exercises, making sure that you do, what we call external rotation exercises, where you're rotating your arm out to the side. That also helps train some of our other rotator cuff muscles that we neglect.

So we have a lot of big powerful muscles that help us rotate inward. Most of them do that. When we talk about rotating our arm to the outside, we really only have two that really do the job. And they get beat up and they get worked really hard, especially if they're not strong enough to be able to compensate. So doing some exercises to help work on those external rotators can also help make that shoulder more robust and longer lived, than sometimes when we ignore it and only work on the front chest and shoulder muscles.

John Horton:

Really quickly, what are some exercises for that then? To help those two that are trying to do all that work?

Dr. Adam Kimberly:

Yeah, yeah. So if you have a band or if you're on a cable at the gym, you set it up at about elbow height and you hold a handle in your hand with your elbow bent at 90 degrees and you rotate out. So if I'm taking my hand from midline to outside, OK? So not pushing my hands together, taking my hands apart, bent at 90 degrees. Doing 10 to 15 reps of that. And usually having something under your arm can help out, like a rolled-up T-shirt or a towel. Because that helps you kind of turn on some muscles in a little different way to make it a little more optimal.

And then also you can take it up to 90 degrees so your arm's out directly at your side and you can rotate up the opposite way. So again, you're taking your hand up and back, almost like you're taking it in the plane of your head. Just again, it's a different way to kind of turn on those external rotator muscles to help get them firing a little bit more efficiently.

And then, there's another group of exercises that I like a lot that, again, anyone can do anywhere. You just lie down on your stomach, you put your hands at your side and you try and lift your hands off the ground or off the bench, squeezing your shoulder blades together. You can do those with your hands directly at your side, do 10 or so of those. Then, you can take them up so you're in kind of a T position, same thing, lifting your arms back, squeezing your shoulder blades back. It turns on all those back muscles, you're lying flat so you have to be in a better kind of thoracic posture, as we call it. You get the right muscles turning on and that takes pressure off that front as well. So 10 to 15 of those, two sets, it's usually a good place to start.

John Horton:

What a great tip, man. That's such an easy stretch to do there and such a simple strengthening exercise. Thank you. It'll be really helpful.

Dr. Adam Kimberly:

Yeah, but it can be deceptively hard sometimes. And so if you're doing them and you find your shoulders shrugging up toward your ears, you're probably doing too many. So again, it shouldn't hurt and you should be able to do it without compensation, as we call it. So without, like I said, shrugging your shoulders up. Those shoulders should be able to stay down and you're really squeezing them back, pinching those shoulder blades together, trying to get those muscles turning on. It turns on that pretty much everything in the back that we were talking about earlier.

Dr. Lauren Wichman:

And I think, too, these things are effective and that's proven by ... you'll see some of the pitchers before they go for a bullpen, they're doing the exact same things that Adam's mentioning with the bands to be able to get ready to throw the baseball at the speeds they do.

Dr. Adam Kimberly:

Yeah. And I mean, it's quick little things. If you have the right position and the right equipment and you can take a little bit of time off, it doesn't take long. But if you can do them, you can do them a few times throughout the day. Or even like I said, just before you go, and you're going to be active before your pickleball, before your tennis, whatever you're going to do. It's just a nice way to prep the joint and get it in a better spot. And make sure that you're in the best position possible to be successful and hopefully not make things hurt.

John Horton:

Now, we've gone over a lot of stretches and little strengthening exercises that you can do. I want to make sure that we also touch on the importance of form. Because it sounds like a lot of these issues start just because you put your shoulder in a bad spot with how you're doing a particular activity or motion, and then it builds up and it builds up and it builds up. What can folks do to make sure that they're doing these activities properly and kind of giving their shoulder the best chance to survive?

Dr. Adam Kimberly:

Yeah. Again, I'm always going to be biased to physical therapy, but not everyone has a physical therapist in their back pocket. Sometimes, just having someone watch you do the exercises can be really helpful. So whether you have a friend or even having a mirror in your gym, that can be a big place because watching what your shoulder is doing as you're doing those exercises.

So generally, like I said before, if you're shrugging your shoulders up as you're doing an exercise, it's probably not the best thing for your shoulder. Unless it's a specific part of that exercise, like a shrug. If you're trying to work your upper traps, that's great. Do a shrug, that's fine. But if I'm trying to lift my arm up overhead and I notice my shoulder really shrugging up, I'm usually overcompensating with other muscles because the muscles I'm trying to target aren't strong enough. So notice that, take some weight down, and then move through that full appropriate range of motion without pain.

Dr. Lauren Wichman:

I think a lot of times, when patients come into my office, they ask, "Well, can you just print some exercises out for me and hand them to me? I can do them at home." And this is precisely the reason why I am a strong advocate for going in person and pretty much never do the just printouts. Because I tell people form is so important. Form, many times ... improper form many times can lead to other injuries that we don't want to have to deal with. And that's why it's so critical to be able to go to PT, not only for them to give you the exercises that are individualized for what you need, but also, they can give you tips on making sure you're doing them correctly, give you prompting to think about when you're doing the exercise that is really, really important.

Dr. Adam Kimberly:

Yeah. I mean, and even once you go to PT, I can't tell you how many times I've given a patient exercises, they've walked out of the clinic, thinking that things are looking fantastic. They come back to me the next week, I'm like, "OK, let's talk about your home exercises. What have you been doing?" And they run through three or four exercises I've never even seen before and they're like, "No, these are the ones we talked about." It's like, "I don't know where you got those from. That's not what we talked about."

So it's being able to review those things, being able to talk about where they should be in real time, and how they should be feeling. And then also, how they can be aware of what the correct exercise looks like. And again, it doesn't have to be a physical therapist. It can be an athletic trainer, it can be a personal trainer, someone you trust, just watching you do it every once in a while to keep you honest and to make sure that you're in the right positions that you need to be. And that's going to be dependent on what exercise you're doing.

John Horton:

It also sounds like coaching is a big thing here. We were talking ... you always see pitchers, and they throw it a certain way, and you look at them and you go, "Wow, your arm is not going to last." Just because of how they're doing it. And it looks violent and it looks like they're torquing their shoulder a little too much. How important is it to really kind of work with a coach to make sure that you're putting your shoulder in the best spot when you're doing these high-impact activities?

Dr. Adam Kimberly:

Yeah. I mean, a good coach can be invaluable for any athlete to make sure that you're doing the right things right and also avoiding those wrong things that could be setting you up for disaster. Because the other thing with it, too, is, like we said, when you have an injury or potentially something's not feeling well, you're going to change your mechanics, you're going to put yourself into a different position where you may be causing more trauma than what you were doing previously.

So a good coach who's able to speak well to pitch counts, how frequently they should be throwing, not making sure that this ... and usually, we see this in younger athletes, making sure that this younger athlete isn't throwing hard every day. If they're throwing hard one day, that they have subsequent days off.

Major League Baseball put together a really great program, it's called MLB Pitch Smart, that anyone can get online. And it talks about at different age levels, how many hard pitches a kid should be throwing. If they do throw so many hard pitches, how many days off they require after that. Because that is a really important thing. You see some of these young guys who are playing pitcher, and then they go and play catcher, or then they go and play third base, and they're making hard throws from each place. And even though it's not specifically a pitch, they're still making hard throws. And that, over time, can cause trauma, can cause stretch, and can potentially cause tendon ligament tears or growth plate fractures in this younger population. So having a coach who's well-versed in that stuff. And also able to correct posture abnormalities or form changes. Yeah, I mean, that's as important as anything.

Dr. Lauren Wichman:

And I think parents being aware of this, too, is really important because I'll see kids that are on multiple volleyball teams or multiple baseball and softball teams. So one coach may not necessarily be aware of the load that each kid is being exposed to at a given week and a given month. And so I think that making sure that, first of all, knowing that these recommendations exist. But then, being really aware and being really cognizant and communicative of what a kid or what the athlete themselves is going through, is really important for prevention from having to avoid any of the stuff we're talking about here.

Dr. Adam Kimberly:

Yeah. I think also the age group has a big thing to do with it, right? Kids generally shouldn't hurt. And by kids, I mean under 16. After we get a little bit older, sometimes you start to develop things as velocities and forces and that kind of stuff going on.

But I mean, I have a 14-year-old daughter who plays volleyball and she's great, I love watching her play. She got her jump serve this year, which is a big, powerful serve and it's hard. If she comes home from practice and she tells me that her low back is hurting or her shoulder's hurting, I'm not just going to be like, "OK, well, that's fine. That's normal." We need to address what you're doing and take some time off and recover appropriately. It's being aware of those things when they come up and how they come up.

John Horton:

And Dr. Kimberly, I know rest is important. But I think we also talked earlier about how there's been a go-to treatment for years, which everyone would say, ice your shoulder. This is what you do after you throw your 80 pitches or whatever, ice it down, do that. You said the logic on that has kind of been changing over the last decade. Can you share what the best practices would be to help with the recovery?

Dr. Adam Kimberly:

Sure. And I don't want to vilify ice because I don't think ice is bad inherently, right? I mean, if ice can help through some neural mechanisms to help take away pain in the short term, and that can be great. But from what we know about tendon healing and tissue healing, we do actually want more blood flow to that area. And what ice does is it constricts our blood supply to that area in addition to having that cold sensation, which can make things feel good. So we're potentially limiting that.

And we used to think it was good because it would limit swelling, but swelling really isn't the bad guy in this. Swelling is your body's way of trying to heal things. And so, usually, just taking some time off from the affected issue. Elevation can be nice, like I said, you roll an ankle, something like that, you elevate that ankle, let gravity help us out. That can be a nice thing to prevent that swelling from just accumulating over long periods of time. But also moving within comfortable ranges, trying to keep that joint moving in places that doesn't hurt. Those muscles pumping can push swelling out as effectively as anything you could imagine, too. So just literally light exercise, moving with how you can, not doing the irritating thing, and then gradually reintroducing activity as you can tolerate, can usually be a little bit better, to then potentially throwing an ice bag on it right away. Dr. Wichman, do you agree? Disagree? What do you think?

Dr. Lauren Wichman:

I definitely agree. I think to your point, too, of early tolerable motion. Although many times people are like, "Well, doc, should I have a sling because this really, really hurts." And I am strong advocate against bringing a sling in if at all possible. The vast, vast majority of the time, immobilizing that shoulder causes that capsule, some of those soft tissues that surround the joint to really tighten down. Which can be a lot more work to try to combat later down the line. Could even lead to a full-on frozen shoulder sometimes. I fully agree with him in terms of trying to get that early motion back and kind of focusing on those kinds of things over time. Rather than icing nonstop over the course of a week or what have you.

John Horton:

What about heat, in general? Like a little heating pad or something, Icy Hot® sort of stuff, things like that?

Dr. Adam Kimberly:

Yeah. I mean, I think heat can be good, too, especially kind of pre-activity to get the muscles turning on a little bit more. And just also help increase blood flow to that area. Again, it can help things feel better, too. It works through similar mechanisms to what cold does to kind of help your brain think about something other than the pain, so it can make it feel good.

And it can help just kind of with some tissue mobility. So like heat on a shoulder, heat on a neck can sometimes make that feel a little bit better in real time, and then it frees up some motion as well. Icy Hot, I'm OK with. I usually don't want an athlete to have to utilize that to get through something. And that's, again, usually our younger athletes, our older guys may need to kind of figure out a way to kind of get them on the field one way or another. But-

John Horton:

…I've got tubes of that stuff hanging around.

Dr. Adam Kimberly:

…yeah, that's right. Again, this is another place where age makes a difference, right? So if you're going out and you're playing golf or something like that and you need some Icy Hot on your knee to make it feel better, go for it. If it's a 14-year-old who needs to be slathering on Icy Hot or slathering on Biofreeze® to go do their sport, I'm more concerned about that.

Dr. Lauren Wichman:

Definitely. I think especially, too, as you're kind of transitioning back into sport, I think that's another plug for a really, really helpful piece of the puzzle that PT brings to the treatment plan is they can really help our athletes. If we have to take that period of rest, we'll get you back to playing sports as soon as you can. I think PT can help, really, us develop that return to sport program, which can be so helpful.

And even back in my soccer days, whether you're like nursing a quad strain or a hamstring strain, one of the first things, as you're kind of gearing back in there, we would all put the little heating pad on there. And that would help get the tissue feeling a little bit ready to transition right to running and playing sports after it's been down for a little bit.

John Horton:

Well, we have covered an immense amount of territory today and just so many helpful things. I guess, before we say goodbye, I'd love for both of you to kind of like one ... just the thing that you want people to take away from this, as far as what they can do to keep their shoulders healthy and keep doing the activities that they love doing.

Dr. Adam Kimberly:

Yeah. I'm still a big advocate of an ounce of prevention's worth a pound of cure. So if you can do things early on, like if you can warm up before activity, if you can focus on your posture throughout the day — because it's the folks who are sitting at a desk all day long and then it's like, "Yeah, I'm going to go rip out 15 games of pickleball right afterward," and then they don't do any kind of pre-work — those are the people who are probably more prone to get hurt.

And so also doing the unsexy things well, getting good sleep, making sure that you're well hydrated, making sure that you're eating a balanced diet. Those things also let tissue heal. That's when our tissue is able to repair. So doing the little things correctly early on can hopefully help you prevent needing to come in to see Dr. Wichman or myself, to where that shoulder can stay in good health and you can stay healthy.

Dr. Lauren Wichman:

And I would say, I completely agree with everything that Adam said in terms of, I think, that my tagline of “motion is medicine” really is something that I emphasize for most shoulder aches and pains that walk in my door. Proper motion as medicine is key, and that's where having somebody with the expertise, like Adam has, to be able to walk you through what that looks like, I think not only helps you for now, but also helps going forward.

John Horton:

All right. Well, that's a perfect way to wrap things up. I feel like I need to, as soon as we sign off here, kind of stretch my shoulders a little bit and all of that.

Dr. Kimberly, I can't thank you enough for joining us here today. And just really kind of letting us in a little more knowledge as far as how we can keep our shoulders working well.

Dr. Adam Kimberly:

Absolutely. Thanks for having me. It's a lot of fun.

John Horton:

Dr. Wichman, obviously, as we learned here, shoulder injuries are just so common. But I was amazed at just how many simple things that we can do to really keep your shoulders strong and maybe kind of ward off some of those injuries.

Dr. Lauren Wichman:

Absolutely. I think Adam did such a good job walking through even just a couple things that everybody can do at home to combat this issue if they are spending time at a desk all day. But then, also the importance of implementing some of these things in a warm-up or in kind of a cool-down before and after an overhead lift, or a tennis match or a baseball bullpen or what have you.

John Horton:

Yeah. And that's the thing, it's not just for people who are throwing 90-plus miles an hour fastballs. It's like all of us are just constantly working our shoulders and just kind of putting a little wear and tear on there, where we could benefit from just some simple measures to stretch things out and just keep that joint loose.

Dr. Lauren Wichman:

I think it's super important to keep our shoulders healthy long term. I think that they can very easily be under stress, whether it is posture or whether it is repetitive overuse. But if we have a few tools in our toolbox to be able to calm things down when they flare up, but then also keep them at bay. I think that Adam did a great job in talking us through all of that. It was just a great conversation.

John Horton:

Definitely. I think we definitely gave people a few extra tools that they can have in their bucket and hopefully keep their shoulders feeling good.

Dr. Lauren Wichman:

Always the goal, and it was such a pleasure.

John Horton:

Definitely.

Well, if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, play hard and be well.

Speaker 4:

Thank you for listening to Sports Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.