I recently saw a fit 74-year-old patient who’d practiced wing chun and tai chi for many years. He came to me because of shoulder pain that was bothering him during the performance of his everyday activities. Even doing slow tai chi forms was problematic because he couldn’t raise his arms above his shoulders anymore. He feared he’d no longer be able to practice or teach his arts.
His X-rays revealed significant shoulder arthritis — so much so that the bone was eroding. My concern was that if he continued putting stress on his shoulders, he’d soon have a permanent disability that affected every aspect of his life. It was difficult to advise him to stop training, but his condition was so severe, I couldn’t let him act in a way that would further the deterioration.
The patient informed me that he’d trained old school all his life. He’d punch a concrete wall every day, and he had knuckles to show for it. To strengthen his bong sao, he’d tie weights to his arms before working out. He said he did these and similar exercises up to three times a day.
That raised many questions in my mind: Did his workouts cause his current problem? How much abuse can the human body tolerate before structures start to break down? How should martial artists regulate their training intensity? Unfortunately, there are no simple answers.
Shoulder arthritis occurs when the cartilage on the humeral head (ball of the joint) and glenoid (socket) wears out. In severe cases, the joint space is lost, and the bones grind against each other. There are several causes of shoulder arthritis, including trauma, inflammation (e.g., rheumatoid arthritis), a large/massive rotator-cuff tear and primary degeneration. No matter the cause, the end result is loss of joint functionality.
People with the problem usually feel pain and stiffness. The pain can be mild and associated only with activity, or it can be noticeable even while resting and may wake a person at night. Stiffness also becomes a problem with everyday activities; sometimes it’s so severe the person can’t reach the top of his head or back.
Shoulder arthritis is diagnosed after a physician obtains a history, performs a physical exam and reviews the X-rays. Initial treatment involves pain management with analgesic and anti-inflammatory medication, lifestyle modification to avoid activities that aggravate the condition and gentle stretching exercises to avoid progression of the stiffness. Painkillers may control the pain enough for the person to continue training. Martial artists will often try to tough it out, ignoring shoulder pain and opting not to use medication. That’s ill-advised. The condition can worsen, and the pain can become so severe that training is impossible.
If the pain cannot be controlled with medication, cortisone may be prescribed. It’s a strong anti-inflammatory that’s injected into the joint. The main risk, albeit a low one, associated with the treatment is infection. The injection should be performed via sterile technique, preferably in a clinic at a hospital. The duration of relief varies. Some patients report lessened pain for a year or more, while others say they notice an improvement only for a few weeks. On occasion, people find no pain relief at all.
Another type of injection, called viscosupplementation, is designed to lubricate the joint. Why does that help? Because arthritis also entails the “drying up” of the joint, meaning that the normal fluid that circulates in it is lost. Therefore, supplemental lubrication can provide relief — according to studies, it’s usually short- to medium-term duration. It may be delivered as a single-dose injection or in multiple doses, often three given at one-week intervals.
If one of the aforementioned treatments helps manage the pain, the afflicted person will want to resume training. I usually advise my patients not to engage in intense workouts because excessive force placed on the shoulder can worsen the condition. I then explain the importance of daily stretching and range-of-motion exercises to counteract the stiffness. The goal, of course, is to prolong the life span of the joint by slowing the deterioration.
If nonoperative treatment fails, surgery may be required. The definitive treatment is shoulder replacement. That involves removing the arthritic surfaces of the joint and replacing them with metal and plastic components. After such a procedure, I always advise against any martial arts practice. Some surgeons, in fact, will perform a shoulder replacement only on sedentary elderly people.
If the patient elects not to have a shoulder replacement, an arthroscopic procedure may be an option. This minimally invasive surgery can address all the non-arthritic causes of shoulder pain (e.g., bone spurs) and improve range of motion. However, it won’t alleviate all shoulder pain and is usually beneficial only for those with mild to moderate arthritis.
Returning to my patient: His arthritis is so bad in both shoulders that the only viable solution is shoulder replacement. However, he insists the pain isn’t severe enough to warrant that. I told him he should stop all training.
I still think about the effects of hard training over extended periods and how it can lead to a breakdown in the anatomy. Yes, such training can facilitate impressive displays of strength and power, but you need to think about the potential long-term consequences. If you don’t moderate your training now to preserve the integrity of your shoulders and other joints, you may not be training at all in the future.
About the Author: Robert Wang, M.D., is a Fellow of the Royal College of Physicians and Surgeons of Canada. He’s an orthopedic surgeon specializing in sports medicine.