Have you ever trained a client with persistent shoulder pain? Maybe you have worked with someone in the past that always seems to complain of a mild ache or pinching pain with bench press. What did you do? Modify the training or avoid upper body exercise altogether? Perhaps you even considered pushing through it because you sensed it was just muscle soreness. How do you really know?
This scenario is all too common in gyms and studios today. Members and clients have little if any knowledge about shoulder pain and its affect on exercise. More importantly, they are not likely to recognize pain related to certain exercises immediately. This makes the job of fitness professionals all that much more difficult. Trainers must be aware of common shoulder problems and how they impact training considerations if they want to avoid shoulder injuries and maximize their clients’ results.
Walk into a large health club tomorrow, and you will witness the complete destruction of the rotator cuff as people naively do lat pull downs behind the head, exhibit improper form on the bench press, and most often, attempt to lift far more weight than they can safely handle. What about those group fitness classes where there are never enough light dumbbells for everyone? Inevitably, someone (usually the middle aged novice exerciser) tries doing lateral raises with eight or 10 pound dumbbells when s/he should really only be using four or five pounds. The result is an inflamed rotator cuff and an unhappy client who gives up on exercise because of the association with pain. Unfortunately, this can be real life today in the booming fitness industry.
Given the increased interest from baby boomers, fitness professionals are faced with increasing challenges in the personal training field today. Many of these prospects have had or will have shoulder pain of some kind. Keep in mind that approximately 30% of the population will suffer from rotator cuff pain. Others may have labral (shoulder cartilage) tears, shoulder instability or previous shoulder dislocations. All of these injuries have a direct effect on weight training.
Now, most trainers can not and should not be expected to have the knowledge of a physical therapist. However, they should seek out as much knowledge as possible about common shoulder injuries and conditions and discover how these problems affect their selection of training modes, intensity and progression with clients. This can be done through continuing education, extra certifications, research and developing strategic alliances with respectable health care professionals.
Networking with physical therapists and physicians will only speed up your learning curve, improve your credibility with clientele and provide a trusted resource when you have questions about training individuals with shoulder problems. Trainers should be careful not to over step their bounds by attempting to treat a problem with a few exercises they saw on the web or in a recent magazine given the fact they are not really skilled or educated in medical evaluation procedures. Leave this to the doctors.
In coming sections, I will outline some of the most common shoulder problems you will encounter with clients. Keep in mind that this information is intended to provide a brief overview of common signs, symptoms and recommended training modifications. You should not necessarily base all training decisions on this information as conditions and response to exercise may vary widely from person to person.
Instability basically means that a person has increased mobility or joint play in the gleno-humeral joint (shoulder). This may be the result of a past dislocation, repetitive activity (swimming or throwing) or simply inherent to that individual. It almost always involves stretching or tearing of the labrum.
Generalized joint laxity is more common in women. Treatment may include immobilization (sling) for a given period of time, surgery or rehab. Those under the age of 25 are more prone to suffer recurrent bouts of instability unless they undergo surgical repair, while those over age 25 typically recover well with rehabilitation.
Common weight training exercises that place the shoulder at risk are bench pressing, shoulder pressing, rows beyond the plane of the body, flies, behind-the-head bar squats, dips and push-ups. While these exercises are not absolute contraindications, you need to be aware of the following considerations:
- Acute or chronic condition
- First time injury or recurrent problem
- Age of the client
- Functional needs and goals of the client
- Past treatment and results
- Limitations imposed by physician, if any
It is not likely you will be training someone with an acute dislocation or subluxation (shoulder comes out momentarily and reduces on its own) as these conditions typically require medical intervention. However, it is possible that you may have an athlete or client with chronic joint laxity or instability that has a history of prior dislocations or subluxations. Therefore, you need to understand how loads applied in certain points in the range of motion pose a risk to the shoulder.
In most shoulder instability cases, people suffer from anterior shoulder laxity or dislocations. This means placing the shoulder in extreme overhead positions, behind the head or fully extended beyond the body may lead to pain or damage to the shoulder with external loads.
Rotator Cuff Disease
The rotator cuff consists of four small muscles that form a sleeve around the shoulder and allow us to raise the arm overhead effectively. These muscles, consisting of the supraspinatus, infraspinatus, teres minor and subscapularis, oppose the action of the deltoid and depress the head of the humerus (upper arm) during shoulder elevation to prevent impingement. Rotator cuff injuries such as tendonitis, bursitis and tears are common among certain populations.
The most commonly injured muscle is the supraspinatus. It is responsible for initiating and aiding in elevation of the arm. If torn, the individual typically experiences persistent pain in the upper lateral arm and significant difficulty raising the arm without compensatory motion from the scapula (shrug sign). The hallmark signs of a supraspinatus tear are nocturnal pain, loss of strength and inability to raise the arm overhead.
Acute tendonitis may also present with similar signs and symptoms, as pain can inhibit motion and strength. However, symptoms associated with tendonitis normally respond to rest, ice, anti-inflammatory medication and therapeutic exercise. Pain is often described as a dull ache or sharp pain along the top of the shoulder or upper lateral arm.
Rotator cuff tears are most common in men age 65 and older. Tears and/or injury are typically related to degeneration, instability, bone spurs, trauma, overuse and diminished strength/flexibility related to the aging process. However, youth are also at risk for injury if they are involved in repetitive overhead sports including swimming, volleyball, baseball, softball, tennis, gymnastics, etc. It is also important to mention that instability can contribute to secondary rotator cuff pain and inflammation.
The key to avoiding rotator cuff injury is performing adequate conditioning prior to stressing it with vigorous activities. Many weekend warriors try to pick up the softball, baseball, football, etc. and begin throwing repetitively and forcefully without properly warming up. In addition, they are not likely to condition before the season like competitive athletes. This often leads to excessive strain on the rotator cuff and swelling. The inevitable result is soreness, especially with overhead movement or reaching behind the back. The act of throwing is the most stressful motion on the shoulder. The rotator cuff is forced to decelerate the humerus during follow through at speeds up to 7000 degrees/second. Without proper strength and conditioning, the shoulder easily becomes inflamed.
Since the rotator cuff muscles are small, it is best to utilize lower resistance and higher repetitions to sufficiently strengthen them. Sample exercises include Theraband or light dumbbell external and internal rotation exercises and scaption, which can be performed at various degrees of abduction. In addition to cuff specific exercises, it is also important to strengthen the muscles around the shoulder blade. These exercises include wall push-ups with a plus (rounding shoulder blades), shrugs, rows and lower trapezius exercises.
Specific rotator cuff exercises can be incorporated into upper body workouts. Perform two sets of 15-20 repetitions for each exercise. These exercises should be done no more than three times per week to avoid overtraining.
In regard to osteoarthritis, this is a natural aging process that affects everyone differently. Some contend that wear and tear based on individual activity levels will accelerate the process. While this may be true in some cases, I would hesitate to tell you that this is a hard fast rule. Furthermore, arthritis in and of itself does not guarantee you will experience significant pain or any pain at all. With arthritis, bone spurs, calcification and damaged cartilage lead to a reduction in joint space and pain. Over time, motion and strength become compromised.
The key to managing this condition is avoidance of abusive activities (typically high impact, compressive forces) and a moderate strength training program. Ice and anti-inflammatory medication are often prescribed during periods of soreness. Heat may also provide symptomatic relief and aid in loosening up the shoulder. Proper warm-up prior to training is a must every time you perform weight training.
Comprehensive exercise protocols should include strengthening for the scapular stabilizers and rotator cuff musculature coupled with stretching to reinforce proper posture and alignment. Rounded shoulders or slumping posture actually reduces the space that the rotator cuff occupies, thereby making it more likely that you may suffer from shoulder impingement (leads to rotator cuff pain). Remember when your parents told you to sit up tall? Now, you can see that they really did know what they were talking about.
Signs of arthritis:
- Generalized aching in the shoulder joint, although may experience similar pattern of pain as in cuff tendonitis
- Limited range of motion/stiffness
- Grinding or grating (crepitation) in the joint
- May experience increased pain in cold weather or periods of higher humidity (rain)
- Loss of strength namely due to pain inhibition
Rules and Exercise Guidelines
All of the previous conditions can complicate, limit or prevent you from utilizing certain training techniques. Having a good understanding of each condition will allow you to design safer, more effective training programs. And the best part of all is that the exercises and modifications for each particular condition are generally the same. You basically need to obey the following rules:
- Avoid extreme ranges of motion with certain lifting movements, as loading the shoulder at end range places harmful stress on the shoulder joint (e.g., full range bench press, full range dips and full range push-ups)
- Avoid any activity that causes or markedly increases shoulder pain
- Perform postural stretching (especially the pecs)
- Perform scapular stabilizer and rotator cuff strengthening exercises
Below, I will list modifications of common exercises to minimize the risk of shoulder injury, particularly if a person has a shoulder problem. Please note that improper lifting techniques will undoubtedly create shoulder problems over time due to the repetitive nature of the activity coupled with heavy loading.
- Bench press – Do not lower the bar or dumbbells below where the arms are parallel to the floor
- Shoulder press – Keep the arms 30 degrees in front of the body and do not lower much below where the arms are parallel to the floor
- Bar squats – Avoid behind the head bar placement and opt for front barbell squats or dumbbells in standing
- Dips – Do not lower beyond the point at which the upper arm is parallel to the floor
- Push-ups – Do not lower below the point at which the upper arm is parallel to the floor
- Rows – Do not pull beyond the plane of the body to avoid excessive strain on the anterior shoulder capsule
- Lat pull downs – Keep the bar in front of the head
- Upright rows – Limit the elevation of the bar or dumbbells to the point at which the arms are parallel to the floor
- Lateral raises – Keep the arms about 30 degrees in front of the body (elbows are slightly bent) and raise the arms no more than shoulder height
These modifications will avoid excessive stress on the shoulder joint capsule and help prevent rotator cuff impingement. They will not limit hypertrophy, strength gains or function. They will, however, ensure that you are training safely and minimizing the chance for injuries. In many cases, clients can continue to train even in the face of some pain with proper adjustments. If you consistently follow these guidelines, you will have happier, healthier clients.