By Peter Madsen • The Bulletin

Preventing and caring for shoulder injuries

Physical therapist Nick Hagen offered a few shoulder injury prevention and care tips. Hagen is a clinic manager and physical therapist at Rebound Physical Therapy. Answers have been edited for clarity and length.

Q: How can you avoid a shoulder injury?

A: Good posture is key to maintaining shoulder health. However, desk jobs induce poor, rounded posture. That will lead to stiffness and affect shoulders’ range of motion, particularly in overhead movements. Preventative measures include sticking with activities that are appropriate for your strength and range of motion. Pushing a heavy weight over your head can be appropriate if your body is conditioned for it. For example, people might get into shoulder trouble while doing a CrossFit exercise that they haven’t done before.

Movements that are best for shoulder strengthening include rowing motions, or backward pulling motions that beef up the muscles attached to the shoulder blades. These exercises can be done at different angles to isolate different shoulder blade muscles.

Rotator cuff exercises are great, but they’re not incredibly functional. Carrying weights or doing planks is good for shoulder muscles, too.

Q: What is good day-to-day treatment for lingering pain in a shoulder that hasn’t experienced any trauma?

A: The pain can originate in the soft tissue, such as the rotator cuff itself or that around the clavicle, ribs and neck, which can get adherent and sticky. These should be stretched out daily. These areas can be stretched by lying on your side and reaching your arm behind your head or moving it in a windmill motion. Stretching the mid-back is crucial, too, and many yoga positions are great for shoulders. Additionally, the core is key to the shoulder’s strength; without it, the shoulder is working in isolation.

Q: After the first dislocation or tear in the shoulder, what are some things a person can do to prevent further issues?

A: This scenario is a little different than treating general shoulder pain. After a traumatic injury, there is excessive looseness in the shoulder. You don’t want to stretch the muscles at all. Treatment is more about stabilization. Doing planks and making a bench press motion with a kettle bell creates stability in the shoulders. You can also do what’s called a “waiter walk,” where you carry a weight like a tray.

Q: What goes on when someone visits a clinic for physical therapy after a shoulder surgery?

A: There are certain precautions after surgeries. If doctors repaired the loose part of a patient’s labrum (rubbery tissue that helps hold the shoulder joint in place), for example, they won’t want that stretched. They will limit the external rotation of the shoulder. For four to six weeks, certain movements will be restricted. The patient will gradually begin lifting weight until reaching the ability to lift weight over their head or replicate a throwing motion — whatever the goal of motion may be. At the three- to four-month mark, high-level overhead strength work comes into play.

Elite multisport athlete ­Sarah Max was competing in a multiday mountain bike race in Colorado when a competitor jockeying for position clipped her handlebars. Max crashed onto her shoulder with almost all of her body weight. She felt a pop. She completed that day’s race stage before being checked out by some doctor friends, rallying to snag second place overall among women in the Breck Epic three-day race.

A physical therapist friend recommended she have an MRI, which looks at the body’s tissues, taken of her shoulder. But she postponed it, and a crash at a subsequent mountain bike race hastened her decision. Another friend, who damaged his shoulder in a car accident, told Max she was delaying the inevitable.

“He was right — I didn’t want this to be this kind of thing that just nags at me,” Max said.

Shoulder injuries are common among those who live active, outdoor lifestyles in Central Oregon. Rips in the shoulder joint’s stabilizing cartilage and muscles are often caused by mountain biking in the warmer months and skiing and snowboarding during the winter. Shoulder injuries are highest March through July due to overuse during baseball season when unconditioned people start throwing baseballs and softballs.

General aging is another culprit. An old injury that’s caused long-term nagging pain can turn into a torn rotator cuff when people hit their 40s. But that doesn’t mean they need to go under the knife, said Nick Hagen, a clinic manager and physical therapist at Rebound Physical Therapy.

Max, 43, followed her friend’s advice. The MRI showed the crash ripped her labrum — a stabilizing cartilage cup in the shoulder joint. It also showed that her rotator cuff — four muscles that help keep the head of the humerus in the socket — was damaged by the crash.

“I had the MRI on a Tuesday, saw the surgeon on Friday, and I had surgery the following Thursday,” Max said. “Once I knew what was wrong, I just wanted to get it taken care of as quickly as possible.”

A torn rotator cuff and a true dislocation are the two cases in which surgery is highly recommended, Hagen said. Outside of those worst-case scenarios, even rotator cuff tears, cartilage issues and general shoulder pain can be rehabilitated with physical therapy.

“If I took an MRI of 10 people, maybe seven would have a labral issue, but that doesn’t mean they need surgery,” Hagen said. “Sometimes the diagnosis can make it sound worse than it is.”

Max, who is a four-time female winner of the Pole Pedal Paddle, said she had a positive outlook regarding the short-term impact that her shoulder surgery would have on her daily routine.

“I had been doing sports all my life,” she said. “At some point, your time is up. And I had a really fun summer. I got to ride my bike a lot.”

Riding her bike included Max’s two fifth-place finishes among women at Rebecca’s Private Idaho, a multiday mountain bike race near Ketchum on Labor Day weekend. After surgery, Max wore her arm in a sling fitted with a supportive wedge for a month. She slept propped up in bed on a mountain of pillows. Friends worried that Max would “go crazy” not being able to do the sports she loves.

“Yes, I’m beginning to get excited about getting on a bike again and skiing and running,” Max said. “I’ve been riding my trainer, sweating a little bit, taking some spin classes and walking around a lot. … It’s actually been great.”

While Max now spends most of the day free of the sling, she still wears it at night.

She attends physical therapy several times a week to regain motion in a shoulder that now feels very stable.

Paying the piper

Bend resident James Williams, 38, knows the agony of shoulder dislocations. As a teenager he developed a click in his right shoulder while whitewater kayaking near his native Chattanooga, Tennessee. One day, in trying to keep up with more-­advanced friends in a rain-swollen creek, Williams popped his shoulder out of its socket by frantically paddling his way out from beneath an undercut rock where he was stuck.

“The force of me trying to roll put my shoulder into my arm pit,” said Williams, who swam to shore. His friends were able to reinsert his shoulder.

“It hurts,” he said. “It’s a traumatic sensation knowing that a major joint is so far out of place.”

From then on, Williams would pop it out by innocuous things like sneezing or reclining while propped up on one arm. “I have six high school buddies who are very keenly aware of how to put a shoulder back in,” he said with a chuckle. Subsequent dislocations forced Williams to give up kayaking in college. He sought an orthopedic surgeon known for working on the joints of professional athletes Nolan Ryan and Bo Jackson. During rehabilitation, he caught the cycling bug — and has since become an elite cyclist. But Williams, a former Bulletin sports reporter who teaches English at Summit High School, subsequently messed up his other shoulder since moving to Bend in 2006. While nordic skiing at Dutchman Flat Sno-park, he zipped down a hill past a friend before crashing into a snow bank, dislocating his left shoulder.

“As painful as (a shoulder dislocation is), the implications are more painful,” Williams said. “Knowing that it means surgery and … months of inactivity and rehab. That would really get me down when it would happen.”

Williams’ bike racing friends pointed him toward Michael Ryan, an orthopedic surgeon at Desert Orthopedics. Lying on the operating table, Williams gave his doctor some words of encouragement before being cut into.

“The last thing I remember was trying to focus on him through the haze of the knockout drugs and I said, ‘Dr. Ryan, just tighten the s--- out of it for me,’” Williams said with a laugh. “And he did.”

‘Kind of a blessing’

Anne Linton, 56, knows her way around a serious shoulder injury. During her two-decade career as a physician, her specialties included emergency medicine and orthopedics. A lifelong multisport athlete, Linton has been on both the diagnostic and receiving ends of traumatic injury.

While riding a bike to work at a hospital in Boise, Idaho, in 1997, Linton was struck by a motorist. The collision partially tore her rotator cuff and broke her hand.

The injuries required a year of rehabilitation, after which she received surgery to alleviate an impingement in her shoulder. Linton stopped playing tennis and picked up triathlons, competing in an Ironman and others of varying distances. She switched to bike racing when a knee injury made running unfeasible in 2009. In 2016, Linton volunteered at the High Cascades 100, a 100-mile mountain bike race in the Deschutes National Forest, as a sweeper. She raced it twice. But a physical therapist told her to take it easy after returning from her third knee surgery in 2014. Cruising on her mountain bike to clear the last half of the course of any lost or injured racers, Linton she slid out on pine needles near Mt. Bachelor and crashed.

“My shoulder didn’t dislocate. Something just ripped,” said Linton, who “shook it out” before she rode the last of the course. When she tried to help pull up course markings, however, she couldn’t raise her arm. An MRI showed that Linton severed her supraspinatus — one of the four muscles in the rotator cuff. She put herself under the surgeon’s knife within a week.

“Waking up post-op was the worst pain I’ve ever felt in my life,” said Linton, placing it somewhere between a nine and a 10 on the pain scale. “But I haven’t had children, though — I will be honest.”

Linton, who owns and operates Anne Linton Coaching, has assumed a second career as a personal trainer to a stable of cyclists, runners and triathletes. She also teaches spin classes at the Athletic Club of Bend several times a week each winter. One or two participants inevitably have an arm in a sling or cast — an uncomfortable situation Linton is no stranger to.

“In reality, it’s OK,” said Linton, adding that it’s a good idea to bring an extra sling to replace the one that gets covered in sweat. “You can really get in quality training and be very focused. You can also work on your core strength and other areas of your body to help your cycling. … (A shoulder injury) is kind of a blessing.”

— Reporter: 541-617-7816,