Are You Training Yourself To a Shoulder Injury?

As previous personal trainer and someone who has exercised for over 35 years, I am continually amazed at some of the things I will see people do in the gym.  We all see it and often say to ourselves, what are they doing?  As I have matured (gotten older) and now have a much better understanding of biomechanics, orthopedics and pathology, I also know that many of those individuals are training themselves to not only a potential injury but a potential lifetime of orthopedic and joint problems.  So, although this blog was previously posted in May 2013, it was one that had the highest number of views and is worth repeating.  Why?  Because a day does not go by that we don't see people in the gym training themselves to a future problem.

According to the American Academy of Orthopedic Surgeons, of the 10 most common sports orthopedic injuries, shoulder injuries rank #6 (labral tears) & #7 (rotator cuff tears).  However, with weightlifting the shoulder is the #1 most commonly injured joint.  The most common structures injured in the shoulder with weightlifting are the labrum, rotator cuff, biceps tendon and acromioclavicular (AC) joint. We see this everyday.  People give us the perfect tell tell sign.  What is it?  You must read on to find out.

Shoulder Joint

First, why is it that the shoulder is the most common injury in weight lifting?  There are a lot of reasons for this, including the architecture of the joint and the training techniques we use.  Looking at architecture of the shoulder (diagram), you can see by design, it is an inherently unstable joint.  Unlike a ball and socket joint (like the hip), it does not have a bony structure which provides its stability.  This instability or design allows it to have a tremendous degree of freedom and is one reason we are able to move our shoulder more than our hip, knee or ankle.  It is also the reason that it is more susceptible to injury with over head activities and weight lifting.  

Key Training Note:  Range of motion of the shoulder is important and you should have full range for exercise.  However, the shoulder is an inherently unstable joint.  The last thing you want to do is exercises which increase the instability.  All too often people will use a dowel as a warm up where they repeatedly bringing the dowel over their head and continue to excessive shoulder range of motion.  This creates excessive range and is not healthy for the shoulder.  Often, many will rub the anterior capsule (front of their shoulder) after which is your shoulder telling you it hurts.

Due to the architecture, the shoulder's stability is provided by the ligaments and muscles that surround it.  This means the ligaments must remain taunt (not hypermobile) and the muscles need to have a high level of strength and endurance, specifically the scapula stabilizers and rotator cuff muscles.  Therefore targeted training to the stabilizers of the shoulder, specifically the rotator cuff (supraspinatus, infraspinatus, subscapularis and teres minor), serratus anterior and parascapular musculature (rhomboids/lower trap) is needed.  One reason it is commonly injured is we rarely train these muscles in isolation or train them properly.  Often when we do train them, it is with improper technique and therefore the exercises are ineffective at strengthening the muscles we think we are targeting.

Key Training Note:  The rotator cuff is a high endurance muscle.  It is active with every movement of the shoulder and therefore must be trained as a high endurance muscle.  This means you train it with a lower load and much higher repetitions (8-10 reps does not cut it for rotator cuff).  Positioning of the scapula and cervical spine is also critical to ensure you are not impinging on the rotator cuff or long head of biceps during the exercise which you are trying to strengthen your rotator cuff.  So, when doing rotator cuff exercises (whether standing or side lying), bring your chest up and pinch your shoulder blades back and down.  

Hawkins Test

The other reason the shoulder is commonly injured is the exercises we choose to perform for strength training often place the shoulder in compromising positions.  For example, during an orthopedic exam, there are several tests that we do to diagnose a shoulder problem (we will only name a few here).  Whether it is the Neer’s Test (impingement test), the Hawkin’s Test (impingement test), Obrien’s Test (labral test) or Apprehension Test (shoulder instability test), the intention is to put you in the position that stresses the tissues to elicit pain and/or symptoms.  Hence, if you place your shoulder in these compromised positions and stress them under load (i.e. weight lifting), you are creating an injury.  Knowing this, it makes sense that you would want to “avoid” these motions with lifting with weights if you “know” they compromise the tissue.  Yet, that is exactly what many of us do.

OBrien Test

Below is a list of each of the test along with some of the most common exercises we do that mimic these “compromising” positions:

Neer’s Test - this test brings shoulder into flexion beyond 90 degrees causing the supraspinatus to become impinged in the subacromial space.

• Front and lateral raises above 90 degrees with palms down impinges the supraspinatus tendon in the subacromial space.  Modification - simply change the position of the hand to thumb up position which clears the supraspinatus tendon
• Stretching full body weight on TRX bands with shoulder above 90 degrees puts a tremendous amount of load on the supraspinatus tendon as well as stretches the anterior capsule especially if you are trying to relax your shoulder during.  Modification - don't do under body weight.
• Push-ups with shoulder flexion >90 degrees pinches your supraspinatus with every rep under body weight.  This is increased if you have your head forward and your scapula are winging during.  Modification - don't do with the shoulders above 90 degrees and modify if your scapula wing a lot.  If they do, this is an indication of serratus anterior weakness and you should include this in your strengthening program.

Hawkin’s Test - as you bring the shoulder into flexion and internally rotate, you pinch the supraspinatus in the subacromial space.

• Upright rows above 90 degrees - this not only impinges the rotator cuff but when done in combination with the shoulders rounded forward, there is an increased impingement on the labrum and biceps tendon as well.  Modification - do reverse uprights or do uprights but do not bring above 90 degrees.  
• Standing external rotation on cable with shoulder above 90 degrees - this is a common exercise in rehabilitation but it is one that is done wrong most of the time in the gym.  Most do with too much weight and while performing with poor posture.  Modification - do this in a sidelying or standing position in the scapular plane (demonstrated).  

Apprehension Test - this is a test where the shoulder is in 90 degrees adduction and 90 flexion and is externally loaded to test the integrity of the anterior capsule and ligamentous structures.   

• Shoulder press/lat pulls behind the head - this puts a tremendous tensile load on the anterior capsule and ligamentous structures.  If done under load, this compromises the integrity of the shoulder's stability.  Modification - simply do them in front.  The training benefit is the same and the stress to the shoulder is much less.
• Pec deck past 0 degrees of shoulder extension is a huge stress to the anterior capsule as well as the labrum of the shoulder.  Some will even relax when they get to the end range which makes this stress even worse.  Modification - only take to neutral shoulder extension and not past.

So what is the tell tell sign?  Simple.  If you get up from your exercise and find yourself rubbing a localized spot on your shoulder (typically at the anterior shoulder or lateral shoulder), this is your body telling you what you just did is injuring it.  If you do an exercise that bothers you, you subconsciously take your fingers and rub (usually in a cross friction pattern since this relieves pain) the anterior capsule, long head of biceps or supraspinatus insertion.  So if you find yourself doing this, you need to modify that exercise before you cause an injury.

So, is the answer not doing these exercises?  No.  We provided some modifications but exercise is limited only by our imagination.  There are numerous modifications we can do to these exercises which will make them much more effective at strengthening, make them more “shoulder friendly” and aid you in training to prevent an injury.  Since shoulder injuries are so common in weight lifting, don’t try to train through them.  If you are having pain with, see a physical therapist who is a sports certified specialist or athletic trainer who can assist you in remaining pain free while achieving your fitness or performance goals.

We hope that you found this blog insightful and useful.  As we stated previously, stay tuned and if you like what you see, SHARE THE PASSION!  It is the biggest compliment you can give.  Follow us on Twitter @ACL_prevention and tweet about it.  #DMAOnTheMove and help us spread the passion and #movementonmovement #PT #ATC #ACLChat.

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Trent Nessler, PT, MPT, DPT:  CEO/Founder ACL, LLC | Author | Innovator in Movement Science and Technology.  Dr. Nessler is a physical therapist and CEO/Founder of ACL, LLC.  He is the researcher and developer the Dynamic Movement Assessment™, Fatigue Dynamic Movement Assessment™, 3D-DMA™, author of the textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and associate editor for International Journal of Athletic Therapy & Training. For more information, please see our website at www.aclprogram.com