shoulder pain

Pain and the Brain: How to Take Control and Continue Progressing

Let me ask you a question: have you ever been in pain? Not fun right?

If you’re lucky, it only lasted a few minutes, or several hours, but there are those of you out there who’ve suffered for days, weeks, and maybe even years.

Maybe it was from a strained muscle during your last sprinting session, or a rolled ankle in a pick-up basketball game. Or maybe you injured your back years ago deadlifting, and it hasn’t been the same since.

Regardless of the cause, pain can be both frustrating and confusing. It can leave you feeling hopeless, consume much of who you are, and prevent you from doing the things you love or once loved.

If you Google “pain relief” you’ll quickly get 181,000,000 results that vary from medication and topical cream, to electronic devices and various stretches. Deciding the best course of action to take can be overwhelming and expensive.

When it comes to pain, like anything else, knowledge is power. And being able to understand what ignites your pain is often the first step towards getting back under the bar, on the field, or doing whatever it is you’re passionate about.

Pain Protects You

For starters, it’s important to understand that pain exists for a reason: IT PROTECTS YOU.

It’s there to alert you of danger, and signal for you to stop doing x before you become seriously injured. Not only that, it can make you move, think, and behave differently because it has your best interest at heart: survival.

Thus, whether you like it or not, pain is often vital for healing.

When thinking of pain and your body, think of Kevin McCallister protecting his house.

Photo Credit:  Twentieth Century Fox, Home Alone
Photo Credit: Twentieth Century Fox, Home Alone

Instead of staple guns, paint cans, and a rope soaked in kerosene, you have a motor system, nervous system, endocrine, immune, and limbic system all trying to protect and alert your brain of potential damage.

And instead of the wet bandits, you deal with many sensory inputs that serve as threats to you and your body.

In other words, you have a system. And that system alerts your brain of actual or potential tissue damage when it’s under threat.

It’s also important to understand the amount of pain you experience doesn’t necessarily relate to the amount of tissue damage. Your brain is constantly receiving sensory cues and inputs, and has the final say on whether something hurts 100% of the time.

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To get a better appreciation for how significant a role your brain plays in pain, it’s powerful to understand context and emotional stress:

- A cut on the index finger of a baseball pitcher may be much more painful than a cut on the index finger of a sweeper on the soccer team.

- The loss of a loved one, a bad break-up, or taking on more responsibility at work can increase both muscle tension and pain.

- You have the power to take control and inhibit your alarm system.

Understanding Your Danger Alarm System

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Now that you recognize your brain is the boss and has the final say in pain, it’s also valuable to know that pain is NOT all in your head. There are specific physiological processes occurring that lead to pain.

Mechanical, chemical, and temperature sensors all tell your brain about changes in your body’s tissues, and your thoughts and beliefs are constantly influencing how you perceive these inputs.

After your brain takes into account all of the available information, it quickly decides if any of these sensors are sending danger signals. If so, pain is produced.

Photo Credit:  Butler, Mosey.  2013.  Explain Pain.
Photo Credit: Butler, Mosey. 2013. Explain Pain.

The first important piece to appreciate about your danger alarm system is that sensors have an incredibly short lifespan of only a few days. Therefore, your current level of sensitivity is not fixed.

If you can reduce the demands for the production of that particular sensor(s), you’ll reduce the rate of sensor manufacturing, and in return, reduce sensitivity.

This may mean:

- Inhibition of particular muscle chains

- Decreasing sympathetic nervous system activity

- Decreasing daily mental and emotional stress

- Improving exercise technique

- Eating an anti-inflammatory diet

So, how does sensor and sensor activity relate to pain?

We don’t actually have pain receptors, but we do have nociceptors.

Nociceptors respond to everything. If something is potentially dangerous to your tissues, they’ll send a signal to your spinal cord and then your brain.

We have nociception happening all of the time, but only sometimes does it result in pain.

Wait, what?

Remember: when your brain receives an input it’s weighed with all other inputs and then makes a decision as to whether something hurts or not.

The second important thing to know when talking about your danger alarm system is that your brain is constantly changing and creating neurotags.

A neurotag is something that’s specific to you, and is very dependent on your past experiences. For example, if you were in a motor vehicle accident, the simple act of getting into a car may be threatening and cause an increase in muscle tension.

Here’s another example: the longer you’ve had a particular pain, the better your system gets at producing it.

  1. Furthermore, the stronger and larger that pain neurotag becomes, the easier it is for that particular pain to be ignited.

Think of your brain like a football team:

The longer you’ve dealt with your pain, the better your team gets at running your pain play. And you continue practicing that same play over, and over and over again, while neglecting other options in the playbook. Before you know it, your offense loses variability and can only run one play.

No team wins running only one play. You must teach your offense to be curious, creative, and run a variety of plays; this is when your danger alarm system can be shut off.

Learning to drop off these neurotags and replace them with better references can be extremely valuable.

Tissue Damage

Because your danger alarm system is in place to protect the tissues of your body, it’s important to discuss what’s happening locally, at specific tissues, that causes your brain to tell you to hurt.

In the case of an acute injury, your aim must be to return the injured tissue to a functional state as QUICKLY AS POSSIBLE.

Sometimes rest is best, sometimes movement is needed, other times you may need to intervene via diet, drugs, or surgery.

Pain is sensed via tissues because of inflammation, slow healing, or the tissues become unfit and unused. Movement and massage become important tools for moving tissues and sending safe impulses to your brain to help it construct positive outputs.

All tissues have a healing time, and once the healing time has passed, your tissues don’t get another chance. Managing tissues initially involved in an injury will help manage your pain down the road.

Altered Central Nervous System Alarms

Photo Credit: Butler, Mosey. 2013. Explain Pain.

Photo Credit: Butler, Mosey. 2013. Explain Pain.

Tissues that don’t heal properly can alter the processes of your highly adaptable central nervous system.

Remember: your brain is the command center of your entire alarm system and makes the final decision as to whether or not you are in pain. When dealing with continual impulses from weak, scarred, inflamed, or acidic tissues, your neurons and spinal cord adapt to meet the consistent demand.

At the dorsal root ganglion (DRG), a bulge before your peripheral nerve enters your spinal cord; messages from your tissues undergo some evaluation. Your DRG is sensitive and changeable and may send inaccurate signals to your brain, like telling it there is more tissue damage than there actually is.

Your DRG is also vulnerable to hormonal and chemical changes in your blood when you are stressed, which can cause signals that shouldn’t be perceived as dangerous as threatening.

The better your spinal cord gets at sending this danger message to your brain, the more sensitive your alarm system becomes.

Photo Credit: Butler, Mosey. 2013. Explain Pain.

Photo Credit: Butler, Mosey. 2013. Explain Pain.

When your alarm system becomes more sensitive, Kevin McCallister has to go from setting up a few Christmas ornaments on the floor to installing a super alarm system with infrared and motion detectors. Now any little input will trip the system.

Signs and symptoms of a sensitized central alarm system (an offense stuck running one play) include:

- Persisting pain

- Pain that is spreading

- Pain that is worsening past acute phase

- Lots of movements (even small ones) hurt

- Pain is unpredictable

- Other threats in life: previous, current, and anticipated

When your nervous system is continually in fight or flight mode, your brain is priming your muscles accordingly. Big boys like your erector spinae, lats, quads, and pecs are always on.

These long-term motor changes make you behave differently, hold yourself differently, and even talk differently. It can be challenging to reverse these learned patterns.

Taking Control

Step 1: Understand and Educate

If you’ve made it all the way here, you’ve already begun taking control. Developing an understanding and educating yourself about the physiology of pain can reduce the amount of threat you feel.

REDUCED THREAT HAS A POSITIVE EFFECT ON ALL THE INPUT AND RESPONSE SYSTEMS.

Many of us don’t like not knowing, and knowledge can be powerful in helping reduce the hurt you feel.

Step 2: Identify Ignition Cues

Much of the article educated you on sensory inputs that inform your brain of threat. Discovering what these inputs, or pain ignition cues, are is what will set the stage for active strategies you’ll implement to inhibit your danger alarm system.

These inputs can come from many different sensory cues and scenarios.

They vary from overactive chains of muscle at your pelvis, thorax, or cranium. Or could even come from your vision or feet.

Non-physical ignition cues that are often forgotten include mental and emotional stressors, or a poor diet.

If you go to a health-care professional to help you identify your ignition cues, it’s important that they can answer all of your questions, and make clinical decisions based on your particular presentation and objective tests that he goes over with you.

Step 3: Learn Active Coping Strategies

With your ignition cues identified, you can now go about implementing active coping strategies. These may include:

- Learning about the problem

- Exploring ways to move

- Exploring and nudging the edges of pain

- Staying positive and establishing a supportive and enthusiastic team around you

- Making plans

- Finding de-stressing activities

Step 4: Your Hurts Won’t Hurt You

Once you begin to use active coping strategies, remind yourself that hurt doesn’t always equal harm.

Step 5: Pacing and Graded Exposure

Your nervous system needs you to gradually increase your activity level. Be patience and persistent.

- Choose an activity you want to or need to do more of

- Find your baseline

- Plan your progression

- Don’t flare up, but don’t freak out if you do

- Look at the whole picture. Stressors come from various places in your life

Closing Thoughts

Much of this article touches on what happens when pain persists long past the time it takes for tissues to heal.

If you’ve recently had an injury, remember to manage your tissues and manage other stressors in life, like getting better sleep, better nutrition, and making time for things like meditation.

If your pain has been persistent and worsening, think about what happens when your nervous system becomes sensitized and you install your super alarm system. Learn active coping strategies and teach your offense to run new plays.

Be curious, be creative, feel, and find yourself living a much happier and pain free life.

about the author

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Mike Sirani is a Certified Strength and Conditioning Specialist (CSCS) and Licensed Massage Therapist. He works at Pure Performance Training in Needham, Massachusetts. He earned a Bachelor’s of Science Degree in Applied Exercise Science, with a concentration in Sports Performance, from Springfield College, and a license in massage therapy from the Cortiva Institute in Watertown, MA. He was also a member of the Springfield College baseball team, and interned at Cressey Performance in Hudson, MA.

References

Butler, D., & Moseley, L. (2003). 

Explain Pain

. Adelaide City West, South Australia: Noigroup Publicatinos.

Training the Rotator Cuff: Assessing and Programming for Optimal Shoulder Performance

Whether you’re an aspiring collegiate baseball player trying to improve throwing velocity, or a weekend warrior trying move serious weights, it’s important to understand how to keep your shoulders healthy to truly maximize the benefits of an aggressive strength training program. As a coach thats worked with hundreds of baseball athletes, I'm often asked how to incorporate certain exercises to have strong and healthy shoulders. Given the unique velocity and range of motion demands of the baseball players that I work with, I've learned some important lessons on how to keep shoulders both moving and functioning properly.

So...here we go.

The Cuff

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The rotator cuff is made up of 4 muscles (supraspinatus, infraspinatus, teres minor, subscapularis), and its main role is to keep the humeral head centered in the glenoid.

While that may sound simple in theory, it's really a complicated process because it's analogous to keeping a golf ball centered on a golf tee. To make things even more difficult, let’s imagine that golf tee is moving:  as you raise your arm overhead to throw a ball or to press a dumbbell or barbell, the position of the scapula will change, so we hope the rotator cuff is able to provide enough dynamic control to prevent contact with the acromion, thus avoiding impingement.

When I first assess clients as they come in, I usually see three main limitations at the shoulder:

1.  Faulty position of the scapula relative to the ribcage

2.  Poor rotator cuff strength

3.  Poor motor control of the shoulder

It’s important to understand the cycle of injury, and how each of these limitations impacts that cycle.  Here's a great graphic illustrating just that.  In particular, this graphic does an outstanding job depicting how a lack of strength (functional instability) can lead to earlier onset of fatigue, poor motor control, and mechanical instability (laxity/pathology).  Aka things we don't want.

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Here's another fun fact to consider before we move on:  cumulative fatigue increases sympathetic tone as a stress response, thus creating sub optimal joint positioning (cue mind blowing).

All in all, what we're talking about is balancing position, strength, fatigue and motor control.

It's All About Position

When looking to enhance shoulder health, it all starts with making sure you have ideal joint positioning. If the muscles can’t generate good leverage and moving segments don’t articulate well with stationary segments, a joint isn’t going be able to move freely or produce/withstand maximal forces.

A very basic example of that can be seen via a length-tension and force-length relationship.  While these graphs are getting after the same thing, I've given you both to help you better understand what's happening:

As the above graphs illustrate, there's an optimal resting muscle length that allows for just the right amount of overlap between myofibrils for force production.  Once you get outside that range, the muscle will not function as optimally (this is what happens when position is out of whack).

Most ardent clients will come in looking something like this:

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They are very Lat dominant, bilaterally extended through their rib cage, with anteriorly tipped scapulae. On the table, they will likely present with bilaterally limited shoulder IR and bilaterally limited shoulder flexion.

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Before we try and do any sort of mobility work, or address rotator cuff strengthening, we need to re-establish a more neutral resting position for the shoulder and optimal starting position for the muscles to do their jobs! I like to start with an All Fours Belly Lift Drill.

All we are looking for here is a good bilateral reach through the floor, creating an activation of both Serratus Anterior (protraction), and creating some desperately needed thoracic flexion. The key once in this positon, is to deeply inhale, getting air into your upper back, then forcefully exhaling and drawing your ribs down. This is repeated for 5 breaths.

Creating Strength

When it comes to strengthening the rotator cuff I usually implement drills focusing on shoulder abduction, or external rotation. These are two motions that will typically fail upon muscle testing. Since the posterior cuff is heavily relied upon to decelerate the arm at the tail end of the throwing motion, I focus specifically on developing the strength of these muscles with our baseball players.

External rotation drills at 90 degrees are usually best, and I will use a variety of dumbbells, manual resistance, or cable resistance.

I look for good ball in socket rotation, and for the client to feel activation in the posterior shoulder, not in the front.

Another drill I started to implement a lot within the last year or so is the Chain Full Can.

I like that this drill utilizes variable resistance from the chains, creating a gradual increase in resistance as the athlete flexes their shoulder in the scapular plane. Also, to be honest, it makes a fairly boring drill typically used with small pink or purple dumbbells into something a little bit more legit.  This matters when you're working with a bunch of baseball players who are secretly enormous meatheads on the inside.

At the initial portion of this movement, if someone has weakness in their rotator cuff they may either crank back into lumbar extension or shrug to compensate their way to the top portion of the lift.  Since most of the links are resting on the floor at the beginning of this movement, the load is less, so the athlete is less apt to compensate to flex their shoulder.   At the top portion of the lift, all of the links are off of the ground and the load is highest where the rotator cuff needs to be strengthened most.

Using chains for this drill also increases grip demands, which causes reflexive rotator cuff activation. And finally, chains are unstable, since they’re suspended in the air, creating the need for added contribution from the rotator cuff to stabilize the shoulder in the glenoid as it goes through a full range of motion.

Control and Timing

The next step is to integrate motor control and rotator cuff timing to ensure proper dynamic stability of the shoulder. Rhythmic Stabilizations are my go to drills to these qualities in varying positions of instability. These drills force you to react to external resistance to stabilize whatever joint is being acted upon, enhancing proprioceptive control and timing of the rotator cuff and the muscles that act upon the scapulae.

These are great drills to train rotator cuff control/timing in various positions without excessively loading up the shoulder. I actually conducted my Master’s Thesis on the implementation of Rhythmic Stabilization drills and their effect on throwing performance. I found that players who presented with a greater degree of laxity benefitted more in terms of throwing performance—measured in velocity. Clients that may present with higher degrees of laxity lack the ability to stabilize their joints through muscle stiffness. Therefore, these drills can be really beneficial in addressing this deficit in motor control.

Where to Go

The big question now is where does all of this fit together into a program? I find that you can split up your rotator cuff strength and motor control work into separate days. For instance, any rhythmic stabilization drills would pair nicely with a primary lower body lift since it's low load and can be done as active rest. I usually program for 3-4 sets of 5-10 seconds depending on number of positions and overall difficulty.

When incorporating direct rotator cuff work, I will put these exercises at the end of an upper body training session to mitigate overall effects of fatigue. I will usually program 2-3 sets of 8-12 reps on a given training day. Try adding these in to your overall training routine and let me know what you think.

Closing Thoughts

It’s important to understand that building rotator cuff strength and control is a sequential process. At each phase of a training program, the exercises must coordinate with training goals. All in all, the key is finding out what you need as an individual and then attacking the weakest link. If you are generally lax, stretching may be the worst thing you can do! However, if you're toned up and positioned horribly, training for stability might come secondary to repositioning and improving range of motion.

I know that was a lot of technical information, so if you feel like you're head is spinning in three different directions don't hesitate to drop me a line below in the comment section.

about the author

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Sam Sturgis

Sam holds a Bachelor’s Degree in Athletic Training from Quinnipiac University (2010) and Master’s Degree in Strength and Conditioning from Springfield College (2012).  A skilled Strength Coach and Athletic Trainer at Pure Performance Training in Needham, MA, Sam works primarily with baseball athletes and clients rehabilitating from injury.  Sam has developed a successful off-season baseball Strength & Conditioning program for youth athletes in the greater Boston area. Sam also serves as the Athletic Trainer for the New England Ruffnecks baseball program.

To contact Sam, he can be reached at ssturgisppt@gmail.com