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February 24, 2012

We lost Tom to golf because of his shoulder, a tale of woe

 

“We’ve lost Tom to golf.”  This is what I heard as I was warming up for my weekly doubles league Tuesday night match.  “Why” I asked, I had heard that his recovery from rotator cuff surgery was going well.  His partner enlightened me.  “His doc told him ‘No overhead sports’ and Tom said ‘the thought of going through another shoulder surgery induces immediate vomiting’”.  Wow this was tough on the league.  We had been scraping the ‘subs’ to keep our full contingent over the last 4 months.  Tom was our most gifted player and pretty much elevated the play of the whole group.  I felt pangs of separation similar to when my best friend moved to Mexico in the second grade.  I knew I would see Tom again, but just like my buddy Karl in 1977, it just would not be the same. We would not have the common ground, common language, and common experience that tied us together.

Middle aged tennis players are a hardy bunch.   We pride ourselves on not verbalizing our complaints.  The evidence of our loss of elasticity, however, is evident in the braces, tape and prolonged warm-ups we now require.  Our ice machine in the tennis house is like an office water cooler, we fill our bags after the match and share a beer with the healing cold draped over our shoulders and knees.  We made it.  We had negotiated a fragile truce with our bodies that allowed our continued participation in a vigorous, competitive, supposedly livelong sport.  “What the hell happened to Tom?”

Well, doggonit, I was going to find out.  Tom was our leader.  Was his fate a premonition?  Were we all destined to the green acreage of the sedate golf course?  Did I need to worry about a chippy 7-iron vs. a lob wedge around the green?  Should I renew my Golf Digest subscription that I triumphantly cancelled in 1998?

I set about answering these questions by going to the source first.  I interviewed Tom. 

Lunch was away from the tennis club.  We were in the first floor restaurant of his office building.  Tom is a successful acountant, at least his large firm bears his name.  He looked sharp in his grey suit, in spite of a gargantuan shoulder sling that held his arm contorted and away from his torso.  I awkwardly shook his left hand.

Turns out there was no aha moment for Tom and his shoulder pain.  Fifteen years of progressive shoulder pain.  No injury, no fall, no “popping” sound heralded this fate.  The pain started with an ache after his toughest matches.  Being the fighter that he is, his self therapy was hitting the gym, weight training.  Over months that served only to extend his pain into the night.  Tom, the prudent accountant, consulted his doctor.  Impingement syndrome was the diagnosis.  He was assured that a round of physical therapy would have pain free in no time.

The physical therapy worked.  He felt so good he added a singles league on Thursdays.   He diligently performed the home exercises and did well…for six months.  When the pain came back with a vengeance his physician ordered an MRI.  “Tom, you have a tear in your rotator cuff” was the assessment upon review of the films. 

He was crestfallen.  “Tears need to be stitched together, right?” he asked.  “Not always” was the answer “Let’s consult an orthopedic surgeon”.  The surgeon prescribed another round of physical therapy.  This time the PT only gave him 2 months of relief.  Tom was on his way to the operating room.

So, I had my tennis buddy’s story of woe, time to consult some other experts. 

Todd Ellenbacher, a physiotherapist in Scottsdale, Arizona and the director of sports medicine for the ATP world, explained “Tennis is pretty hard on the shoulder.”  The problem is a basic one of muscle imbalance in the shoulder joint.  The critical four muscles of the rotator cuff are relatively weak compared to the larger, possibly more glamorous muscles of the shoulder.  The pectoralis, deltoid, and trapezius muscles of the shoulder get stronger with tennis.  The rotator cuff muscles do not.  Turns out that this imbalance can cause major problems. 

Kevin Westrick, a kinesiologist, with Creekside Physical Therapy, has spent 20 years treating shoulder injuries.  He describes the rotator cuff as the muscles that keep the shoulder within the joint.  When the rotator cuff muscles weaken the top of the arm bone tends to squeeze upward, damaging the critical muscles of the rotator cuff.  This process first leads to pain and inflammation.  The inflamed muscles are particularly susceptible to tearing. 

The tennis serve puts tremendous pressure on the shoulder joint.  A 2009 review article in Sports Medicine reports that forces equivalent to 120% of a players body weight are transmitted through the shoulder with each serve.  During this the rotator cuff has to act as “the brakes of the shoulder,” said Paul Borsa, an associate professor of applied physiology and kinesiology at the University of Florida who has studied shoulder injuries. 

Like many in the population at large, tennis players frequently have weak rotator cuff muscles. “Playing tennis builds up the muscles in the front of the shoulder, but it doesn’t build up those in the back very much,” states Mr. Ellenbacher.  The muscle imbalances lead ultimately, to an extremely common type of injury that Mr. Ellenbacher terms “Toyota shoulder-all acceleration and no brakes.”

Tom, Tom, Tom where did you go so wrong?  All he had to do was strengthen the rotator cuff.  Why was this such a challenge?  Mr. Westrick explains the challenges he has encountered over his 20 years of treating the condition. “The shoulder is a beautiful joint-270 degrees of motion in multiple planes.  Isolating the four critical muscles in this sea of movement is not all that easy.”  He describes patients using a common technique of band exercises with faulty technique.  He notes that 17 muscles are attached to the scapula, a bone in the back of the shoulder.  “I have to be standing over the patient, almost constantly, to make sure they are doing it correctly.”

My shoulder is starting to hurt just listening to this.  My insurance has not agreed to my proposal of personal trainer, therapist and technique coach.  I did not even include my hopes of sports psychologist to blossom my budding career.

The current antidotes to this are anti-inflammatory medications, physical therapy and surgery.  None of these sound all that hopeful.  A recent review article out of Australia recently noted that 47% of tennis players suffer shoulder pain.  They glumly conclude that there is no definitive therapy that has been sufficiently proven to address the problem. 

A bit of direction comes from Mr. Ellenbacher “You do not need to use a lot of resistance.  You want to build endurance more than power.”  Mr. Westrick cites research recently published in the Journal of Sports Medicine.  “Nighttime positioning is an important piece of the puzzle.  Many people with the muscle imbalance are hurting their shoulders with sleep position.”

Get the rotator cuff stronger and sleep in the correct position.  OK, how do we do this?  Mr. Westrick endorses a specific product.  “The Rotatoreliever is the one product that I can confidently give to the patient knowing that it is easy to use at home and remarkably effective.” This product apparently has a nighttime component and a unique exercise for daytime.  He states further “this product is getting a lot of attention with my physician colleagues.”

What about the surgery?  There have been numerous advances with surgical techniques that are well publicized.  All of the surgeries now are done laparoscopically ie-small incisions.  I asked Tom to comment.  “The surgery has been tough.  I feel like I am out of commission for 6 months, but I can already tell the pain is decreased,” he says with a weak smile.

Tom ads, “don’t worry about me, I was a 6-handicap before I got cut.”  Superior athletes and their smug confidence will forever vex me.  Good riddance from our tennis house.  Maybe I can finally finish better than fourth in our doubles league.

 

 

 

 

 

 

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