October 16, 2008
Shoulder Injury Prevention – Causes and Solutions
Chronic shoulder pain is nothing new to lifters or overhead athletes. It can range from something you just live with and work around to debilitating and career ending. It is not something you mess with. If you currently have shoulder pain, go have it looked at. If you haven’t experienced it to this point then pay close attention to the following.
Shoulder pain that is chronic in nature is often the result of an “impingement syndrome”. In a nutshell, the soft tissues between the head of the humerus and the acromion and coracoid are literally pinched during throwing, striking, pressing, and other high speed or weighted activities. Those soft tissues include the rotator cuff tendons, the subacromial bursa, glenoid labrum, and even the biceps tendon. Ask an orthopedic surgeon and they will tell you the rotator cuff will look like someone took sandpaper to it and just wore a hole into it. These chronic type symptoms can also lead to acute tears of the cuff, labrum, and biceps tendon which in many cases means surgery and a long, painful rehab process.
So how does one get to that point? There can be any number of causes, the most common of which I will touch on here because they are preventable.
Poor posture – Sitting is a necessary evil for many of us. From sitting in front of a computer all day, to driving for a living, and for students who must sit in class all day. God forbid they’re given a physical education class to run around in and undo what institutional learning has done to them physically. Over time prolonged sitting leads to muscle adaptations. Some muscles become short and tight while other become lengthened and weak. Anyone familiar with Janda’s upper crossed syndrome will recognize this: the tight pecs and levator along with weak rhomboids, serratus anterior, and deep cervical flexors.
What these muscle adaptations do is alter scapular mechanics and gleno-humeral rhythm. The humeral head then rides up into the acromion and/or forward into the corocoacromial ligament causing impingement.
Volume of pressing is greater than pulling – What this does is reinforce the anterior dominance of the pecs in relation to the scapular stabilizers of the upper back. Again, posture and shoulder girdle mechanics suffer.
A lack of stability through the trunk and hips – We have known for some time that poor trunk and hip stability is a prominent cause of shoulder and elbow injury amongst pitchers. This is well documented. More and more research is coming forth looking at these factors with other athletic populations and finding the same results. A study is underway right now looking at swimmers with and without shoulder pain. To this point the leading indicator of shoulder pain is single leg balance (side opposite the painful shoulder). The shoulder will only be as stable as the rest of the body.
Exercise selection – There are just certain exercises that should be avoided by overhead athletes, powerlifters, and Olympic lifters. In particularly bodybuilding type exercises. Heavy shrugs and upright rows, flyes and pec dec for the chest, and front and lateral deltoid raises really should be excluded. It’s rare to see someone performing them correctly and they all increase the risk of impingement through various mechanisms. Little reward for such high risk. If you are a bodybuilder then I understand you must do them but please use a weight that allows you to maintain perfect posture and form.
GIRD (Glenohumeral Internal Rotation Deficit) – This involves the overhead athlete more so than lifters but they too should test themselves (see picture). A difference of 25 degrees dominant shoulder to non-dominant indicates a positive test. GIRD develops because throwing or striking from an overhead position requires a great deal of shoulder joint external rotation. Over time, the athlete develops excessive external rotation at the expense of internal rotation. Physiologically what happens is the posterior shoulder capsule tightens and thickens resulting in superior/posterior translation during the cocking phase, and superior/anterior translation during the follow through. In both instances, impingement can occur as well as significant shear on the labrum.
So now that we have discussed the causes, what should you be doing about it? The following list consists of seven strategies aimed at maintaining shoulder health while maximizing performance. Note: The order of the solutions does not correlate exactly with the order of causes above. The first three solutions are aimed toward improving posture and gleno-humeral rhythm.
Increase thoracic spine extension and rotation – The faulty posture we see so much of is due in part to the rounding of the thoracic spine. The scapulae must be seated properly for normal gleno-humeral rhythm to occur, and this cannot happen with a kyphotic t-spine.
Thoracic spine extension mobilizations can be performed lying over a foam roller. Start at the top of the shoulder blades and work down to just below the inferior angles about an inch at a time. Take 2-3 deep breaths as you relax back over the roll at each level.
Thoracic spine rotation begins sidelying with the top hip at 90 degrees pressing the knee into a ball or the ground, depending on how mobile you are. Roll the shoulders back toward the floor, reach with the down arm, and give a pull on the ribs with the top arm to take the t-spine as far as possible. The goal is to get the shoulders flat on the floor. You will probably see a difference side to side especially if you are a thrower. Work the limited side twice as many sets as the other.
Decrease tone and lengthen overactive muscle groups – A foam roller and/or the massage stick are great for decreasing muscle tone. The main targets in this case are the pecs, upper traps, and levator. Follow up with flexibility work to lengthen the muscles. To get the levator, retract and depress the shoulder blades, tilt your head toward your shoulder, then rotate in that same direction. You will feel the opposite side stretching. Optimal length is chin touching the clavicle. If you know a good manual therapist, take advantage. There are many techniques they can use that you really can’t do well to yourself.
Activate under-active and lengthened muscle groups – Targets in this case would be the lower traps, rhomboids, and serratus anterior. T’s, Y’s, L’s, and W’s are great for strengthening the scapular stabilizers and rotator cuff musculature simultaneously. Be sure to lock the scapulae into retraction and depression before lifting, and go light. It is easy for the upper traps to start taking over especially once fatigued.
Push-ups with a plus are great for activating the serratus. Turkish Get-Ups with a kettlebell is just a great way to put it all together. This is a fairly technical lift and unfortunately a single picture will not do it justice. Those of you who have tried these know how difficult they can be, but are the ultimate shoulder stability exercise.
Adjust training volume front to back – At a minimum, training volume should be 1:1, meaning for every set of bench press, you perform a set of rows. Shoulder press – chins. Flies – reverse flies (posterior delt raise). And so on. Superset the exercises or do them on separate days. It doesn’t matter as long as it evens out in the end.
I know Mike Boyle and others are now advocating kicking it up to a 1:2 ratio as they have seen fewer shoulder injuries using this strategy.
Improve trunk stability – Perform prone and lateral pillar bridges to engage the trunk and scapular muscles simultaneously. Do these in place of crunches during your core work. Yes, I said replace crunches. The only things crunches are good for are increasing thoracic kyphosis, pulling the scapulae into a more protracted and elevated position, and putting undo stress on the cervical spine. All things we are trying to prevent.
Improve hip stability – Single leg squats and deadlifts will force greater hip stabilization versus the traditional squat and deadlift. I’m not saying to replace these, but use the single leg versions of these exercises instead of hitting the leg press and hamstring curl machine. Y can’t go wrong with exercises that challenge everything from the ground up.