Rotator Cuff Aggravation

Anyone else get pain in their rotator cuff from playing? I don’t even have a guitar right now, but when I used to practice, I’d get pain in this area. It didn’t matter what motion mechanic I’d use, or my shoulder position. I even get pain there when I pretend to play air guitar with my arm in multiple positions. I guess I’m unwittingly tensing my shoulder and probably have some mild RSI like a tendinopathy there.

My guess is that your playing position involves internal rotation and abduction of the shoulder with protraction and elevation.

I made a video for another thread recently. It might be helpful for you also.

Thanks, that was helpful. Turns out I’ve done everything bad you said in that video for years, lol. Upper back rounding, shoulder elevation, protraction, internal rotation, etc. It has gotten bad enough that playing air guitar is enough to aggravate it.

I wonder if playing in the classical position would help. Seems like it would. Also, doing vertical pressing exercises feels pretty good. Might do some of those in addition to the exercises in your video. I’m going to have relearn how to play with a relaxed shoulder.

It could. If you make a brief video of your playing I could give you some quick feedback. I’m also available for technical consultations if you’d like to discuss everything in depth.

I actually don’t own a guitar right now. I sold mine a few years ago due chronic RSI issues which have been getting better over the past two years thanks to physical therapy. Unfortunately, I still have a ways to go so I won’t be buying a guitar again until they are totally resolved. But I will definitely consider those consultations if I run into further problems.

For now then, I’d recommend those exercises. They certainly won’t do you any harm.

I’d also suggest visiting a physiotherapist, just incase there is something specific to your personal case.

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Consider the type of Alexander Technique teacher that specializes in musical ergonomics and sit with them, playing your axe. They will see everything and try to help you change towards great ergonomics.

There is no evidence that “bad posture” or any of the movements specified above are harmful or especially likely to cause injury.

There is also no scientific evidence that any of the movements/stretches Tom prescribed do anything beyond providing a placebo effect. That may be a reason to do them but the idea that pain results from “tight” muscles or “improper” movement is baseless.

Finally, the idea these movements are harmless is incorrect. They can be harmful in several ways: one, by cultivating the idea that not doing them will make you more prone to injury, i.e., encouraging hypervigilance with regard to movement which has been proven to make injury and pain more likely. In other words, the more you worry about getting injured, the more likely you are to get injured because pain has a significant psycho-social component. Two, by wasting your time.

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Huge fan of BBM, cool to see someone else here who reads there stuff! I’ve rehabbed five (yes, that many) tendinopathies thanks to their work.

The exercises provided by Tom in his video would be effective at helping to rehab a rotator cuff tendinopathy, provided they were done with progressive loading within pain tolerance. The massages would be helpful for short term pain alleviation, perhaps due to placebo, but you are correct that strengthening must be done to rehab the tendinopathy. I was just at the gym today working out, and while I didn’t do any of the exercises prescribed in the video, I did some vertical pressing and pulling, which worked the external rotators, scapular retractors, and scapular depressors. My shoulder feels a lot better.

I’m not sure that form is entirely irrelevant, however. We know stringhopping leads to injury if it is done to excess (I have personal experience here). Its not that any particular movement is intrinsically bad, but rather the amount of said movement. I believe stringhopping will lead to injury faster than efficient picking, which is why stringhopping is “bad.”

The point of bringing up stringhopping is that some postures may be less injurious than other postures; that is to say, they can be done for a longer time than other postures before injury occurs.

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Great to see another BBM fan on here. You’re right that progressively loading an injured tendon to tolerance will expedite the healing process. This is much different than advocating a litany of stretches, band drills, and massage, all of which are useless.

As far as your particular issue, it seems like you have a good handle on it. Keep loading your shoulder to tolerance at the gym and don’t worry about your shoulder when playing guitar. If you’re not exceeding your pain tolerance, you’re not doing any damage.

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Just from my experience, this is wrong. One instance of “bad posture” will not cause injury (talking strictly guitar playing here, or something extremely “casual” like looking down), but prolonged incorrect movement patterns will likely cause problems to occur. In guitar I had this from prolonged playing on my right leg (tighter QL on that side) as one example… In the “general population” you have several instances of neck pain caused by frequently looking down (likely to your phone) and during the height of quarantine, “zoom neck.”

This is also wrong. Tight muscles may or may not cause localized pain, but the lack of range of motion caused by a tight muscle will require something else in your body to make up for that range. Seeing as you linked barbell something or other, RDLs come to mind. If you have tight hamstrings and attempt a full range RDL, you’re likely making up the extra distance with some degree of spinal flexion (and spinal flexion isn’t “bad”, but it is in this instance).

Also, improper movement is a thing. How is this even an argument? Every joint in your body has an “acceptable” range of motion as well as a strength curve depending on where it is in space. Again with barbell examples: ATG squats. I have a movement pattern to hit depth. If I were to deviate much from that (feet width / angle), I would not be able to hit depth, to say the least.

Your first point is a misapprehension. “Zoom neck” doesn’t occur because looking at your computer is “bad” for your neck. It occurs because people who weren’t used to looking at their computer for long periods of time suddenly had to do so. The problem was they were not adapted to the sudden increase in stress, it was not the movement/position itself. Had they gradually looked at their computers for longer and longer each day, they would likely not have gotten injured (they would have adapted).

Your point about tight muscles is attacking a straw man. I never said lack of mobility in one muscle won’t cause the recruitment of other muscles to compensate. I said pain doesn’t result from “tight” muscles. There’s no evidence for this and, if there is, I welcome you to provide it. When it comes to guitar, we are almost never talking about range of motion limitations for the picking hand. Nor are we talking about range of motion limitations when discussing posture. There’s simply no evidence hunching over while playing guitar is bad for you if you adapt to it, which many (I’d argue most) players do. “Perfect posture” is unnatural, confers no discernible benefit, and is flouted by the majority of players with no ill effects.

This is still an incorrect movement pattern (isometric in this case, but posture is just an isometric movement pattern anyways). The muscles that hold your head up are not meant to be in that position for hours, no matter how adapted you are. At the very least, you’ll end up with reduced “regular” range of motion of the neck, particularly tilting your head back. On top of that, a good majority of the acute injuries associated with this is suddenly doing something that would be expected in “normal life” (such as looking up quickly for whatever reason). Holding an isometric at near end range (in this example, the neck), to the point of near fatigue, then attempting to quickly contract the muscle will have a good chance of injury.

A muscle at rest will probably not cause any pain from being tight (as I said in my last post and to add more clarity: likely only pain if acute injury), but a tight muscle will most definitely cause pain when it’s pushed past its range of motion (which will be reduced if tight).

While I agree that there’s no such thing as “perfect” posture, there is definitely wrong playing posture. Not to mention, having to then carry whatever effects your posture while playing guitar has on the rest of your life. I’ve mentioned my QL (an example of a tight muscle due to guitar posture that felt uncomfortable when trying to push range of motion), but also shoulder rounding = pec and anterior delt tightness, probably rhomboid / mid trap fatigue (same scenario as neck above) etc… All these things may not be uncomfortable while playing, but have a chance to cause problems when transitioning to other activities (or just life).

Everything you’ve said perfectly sums up the conventional wisdom on injuries and pain, which sounds reasonable, but is totally unsupported by actual evidence. As the articles with links to studies I’ve posted above show, injury/pain are the result mainly of overloading a tissue with a stress to which it is not adapted. It is not the result of “tightness” or “bad movements/positions.”

Also, your range of motion point is inapt. Almost never are the joints involved in guitar playing going anywhere near their end range of motion. The obvious exception is finger stretches but that wasn’t the OP’s complaint. Nor do we disagree that if you take a joint with poor mobility and stretch it to its end range, you may cause injury. This is another example of imposing a novel and excessive stress to an unadapted joint. It doesn’t mean big stretches are inherently injurious. Clearly, they aren’t.

I also take issue with this notion of what humans are “meant to do.” Many, if not most, human activities are things we’d never perform in the state of nature, yet they typically don’t cause injury.

Internal rotation of the shoulder with abduction, protraction and elevation closes the subacromial space. This is a simple antomical fact, and is easily seen on a skeleton. The subacromial space houses several soft structures, including the rotator cuff tendons.

There is absolutely a relationship between this specific position of the shoulder and shoulder impingement issues, rotator cuff tendinitis, etc.

Strengthening the shoulder, in particular the tendons of the rotator cuff does not completely negate this issue. As the tendons become stronger, they thicken, making the subacromial space even more confined.

Internal rotation with abduction, protraction and elevation is an inherently weak and strenuous position for the shoulder. This shoulder position is literally the mechanism of the Kimura shoulder lock in MMA and Submission Grappling, which has the highest recorded rate of injury of all submission holds in both competition and training.

Internal rotation with abduction, protraction and elevation is absolutely a “bad” position for your shoulder.

I didn’t demonstrate any stretches.

Rotator cuff tendinitis is absolutely linked with weaknesses of the rotator cuff muscles. The band exercises demonstrated isolate and strengthen those muscles. They should, of course, be performed within tolerance of pain and with progressive loading.

Your premise is that pain and injury are not caused by any particular movements, but a sudden increase in stress beyond what the individual has adapted to accommodate. That is, stress beyond the threshold of what the individuals body is adapted to accommodate.

I am not arguing against this, and nothing I’m saying is inconsistent with that. I specifically mentioned the importance of strengthening muscles to accommodate certain positions and movement patterns. Strengthen your rotator cuff progressively so your rotator cuff tendinitis heals.

Efficiency is the relationship of our efforts (and therefore the stress we must endure) to our effects (what we acccomplish). Inefficient movement patterns and weak positions force us to work harder to achieve the same results, and therefore bring us to the maximum stress we are adapted to accommodate sooner.

A muscle in involuntary contraction is a muscle which is under constant stress, and stress beyond the what your body is adapted to accommodate results in pain and injury. Ending an involuntary contraction reduces stress.

I’ve heard that ending involuntary contractions is more likely about the mind-muscle connection than the muscle itself, and that any affect that stretching, massage, dry needling or bringing the muscle to failure has beyond a placebo is related to those activities temporarily strengthening that connection in the individual. From having spoken to experts directly, it seems that trigger points are a very poorly understood phenomenon, but they are palpable and their presence is correlated with pain and injury.

The OP @crenfb91 is already injured. He has been dealing with chronic pain while playing guitar for years, to the point that he decided to sell his guitars.

I’m not promoting hypervigilence, or trying to encourage a healthy person to spend their time performing strengthening movements to prevent some vague nebulous threat of future injury. The person is injured now.

This depends on your definition of “waste.” You’ve pointed out before that pain has a significant psychological component (which it does). The methods of pain managment we respond to as individuals depends upon our individual psychology, and we must invest our time to find the methods we respond to.

Yes, these exercises isolate and strengthen the rotator cuff if performed with progresssive loading within pain tolerance. Starting with a light weight (like a band) is recommended because it’s very unlikely to provide a stress you cannot accommodate and increase the severity of the injury. If the loads provided by the bands are not sufficient, the same movements could be performed with a cable machine to target the same muscles.

These exercises are by no means the only exercises which can help to strengthen the shoulders.

Yes, massage is very possibley just a placebo. We shouldn’t discount the power of the placebo effect, and it’s been demonstrated that knowing that something is a placebo intellectually does not significantly diminish that effect.

It’s also possible that massage is more than placebo. Seemingly, there isn’t a conclusive answer on this yet.

These are the same muscles worked by the exercises demonstrated with bands, they just weren’t isolated.

Form an movement patterns aren’t irrelevant. Efficient movement patterns from strong positions allow us to achieve maximal results with minimal effort, that is, with less stress upon our bodies. So, we may perform these movements from these positions for longer without stressing ourselves beyond what we are adapted to acccommodate.

Optimising our technique (form and movement patterns) is a method of reducing intensity. It allows us to work less to achieve more.

This, exactly.

I didn’t advocate a single stretch in my video. The movements with bands are specific isolation exercises to strengthen the rotator cuff. Strengthening the muscles of the shoulder in progressive fashion is exactly what you are advocating. Massage may well be a placebo, but placebos are not “useless” and it’s something which I personally respond well to.

I’m in agreement with this.

I disagree. I think that the OP @crenfb91 may well find benefit in retraining his shoulder form to reduce intensity while playing.

Almost never is not never.

I’ve met many players through the years who simply don’t have the limb length and range of motion in the shoulder to accommodate certain picking setups, in particular on dreadnought and jumbo sized acoustic guitars.

I’ve also met many players who position the guitar such that it results in the shoulder of their fretting arm being at the end of its range of motion (adduction with external rotation, retraction and depression, which is another inherently weak position for the shoulder).

You’re generalising your experience of your joints not being close endrange while you play guitar with your specific form and instruments, and positioning. This simply is not the case for everybody, and many people don’t intuitively find something which “works for them.”

The range of motion a joint can adapt to accommodate is not univeral, our individual anatomy must be considered. For shoulder movement, the shapes of a person’s humerous, scapula and clavical are all limiting factors.

Nowhere did I say that you can’t adapt to a hunched posture, or that it’s inherently damaging to adopt a hunched posture provided it is within your body’s tolerance for that position.

I probably spend more time in hunched posture than most people on this forum. It’s absolutely integral to BJJ and Submission Grappling. I’m just mindful of how much time I spend in that posture so I don’t exceed my own tolerance for it, and I work to build my tolerance by strengthening the relevant areas.

To be clear, I have never advocated that anybody rigidly adhere to some idealised “perfect” playing posture.

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@Tom_Gilroy, I take issue primarily with this excerpt from your post:

"Internal rotation of the shoulder with abduction, protraction and elevation closes the subacromial space. This is a simple antomical fact, and is easily seen on a skeleton. The subacromial space houses several soft structures, including the rotator cuff tendons.

There is absolutely a relationship between this specific position of the shoulder and shoulder impingement issues, rotator cuff tendinitis, etc.

Strengthening the shoulder, in particular the tendons of the rotator cuff does not completely negate this issue. As the tendons become stronger, they thicken, making the subacromial space even more confined.

Internal rotation with abduction, protraction and elevation is an inherently weak and strenuous position for the shoulder. This shoulder position is literally the mechanism of the Kimura shoulder lock in MMA and Submission Grappling, which has the highest recorded rate of injury of all submission holds in both competition and training.

Internal rotation with abduction, protraction and elevation is absolutely a “bad” position for your shoulder."

This is incorrect and, again, is a perfect example of a claim that sounds reasonable and has the patina of scientific basis by virtue of its reference to anatomy, but is undercut by the actual evidence.

Anatomy and symptomology do not correlate well. To take your specific claim, the theory of shoulder impingement, wherein the soft tissue components of the shoulder are “trapped” and damaged in the subacromial space, has been debunked. It is a myth that needs to die. Here’s the proof: The Shoulder, Part II: External Impingement | Barbell Medicine

Moreover, the idea that as tendons “become stronger, they thicken, making the subacromial space even more confined” (the implication being that this subacromial narrowing makes an individual more vulnerable to injury) is wrong on its face. If this were true, we should expect to see people with more muscle mass (and, hence, thicker tendons) suffering a higher rate of shoulder pain and injury. The reverse is true, though. You’ll also discover another interesting nugget in those articles, which is that many people with significant partial and full rotator cuff tears have zero pain. Again, pathology visible on an MRI (anatomy) does not correlate well with pain/function.

Here is an article reviewing the current data on the efficacy of rotator cuff surgery. It is remarkably ineffective because fixing a purported anatomical defect does not solve the underlying cause of pain. Shoulder, Part IV: The Rotator Cuff Teardown | Barbell Medicine

To tie this back to guitar, in almost no circumstance is a player going anywhere near the end range of shoulder motion. I don’t dispute that forcing a joint to its end range of motion, as often occurs in martial arts, can cause injury. This, of course, is totally irrelevant to guitar playing, which does not involve nearly the degree of stress or stretch imposed on the shoulder joint. Internal rotation and pronation of the picking arm shoulder (aka slouching) for a normal-sized person on a normal-sized guitar is not dangerous or harmful.

As the remainder of your post consists mainly of you agreeing with me that (1) most of the modalities commonly prescribed for pain are, at best, placebo and (2) placebo can confer a benefit (which I acknowledged above), I would only say that if you are going to share a 15-minute video of band drills, foam rolling, and massages, you should probably advise the recipient that there is no evidentiary support for these exercises in the scientific literature and that they are only valuable to the extent he enjoys doing them.

Probably the best thing someone distressed about pain can hear is that pain is normal, typically isn’t indicative of serious damage, and almost always resolves on its own. It’s okay to feel pain while playing as long as it isn’t debilitating or getting worse. There is strong scientific evidence that not worrying about pain and continuing to move is the best remedy.

I concede that my understanding of the specific mechanism of shoulder impingement is very possibly misinformed.

However, to extend that to say that the internally rotated and abducted shoulder with elevation and protraction is not an inherently weak (as opposed to hazardous) position is something else entirely, and upon that point I would need much more to be convinced.

I think the reality of the situation must be more nuanced than this. Over six years of BJJ I have applied hundreds of Kimura shoulder locks, which place the shoulder in this particular position. People with greater muscle mass (and hence thicker tendons) have a much lesser tolerence for the movement. They also have a much greater awareness of when the shoulder approaches weak positions, and are usually much more insistent upon recovering a stronger shoulder position.

Again, almost none is not none. I have encountered dozens of people who are counterexamples to this (both picking and fretting arms), through some combination of body proportions, mobility, positioning, instrument design or personal injury history.

Who is a normal sized person? What is a normal sized guitar?

There are exceptions. It may be a small proportion but it’s still a numerically large cohort.

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We agree there, in that pain from “tightness” is a tissue that is not adapted to the range of motion demanded of it. And like I said before, the “bad movements / positions” don’t inherently cause pain, but over time they may cause compensation patterns or acute injuries.

A rounded-over playing posture is most definitely end range scapular protraction, which is why I mentioned rhomboids and mid trap.

I also agree there, with the caveat of “time under tension” and load (also velocity if you want to nerd out) but the time portion is what’s relevant to my argument about posture. The body is more resilient than people think, and adapts to new stresses imposed on it without injury (assuming it’s progressed at a sustainable pace). However, humans were not meant to hold positions indefinitely. Either standing with a guitar for hours, or sitting hunched over for hours, or working sitting at a desk for hours. All these things are postural problems, and the ill effects of the last one have been researched plenty. There’s no amount of tissue adaptation that can occur to make that “healthy”.

Overall I think we mostly agree?