How to protect your shoulders from injury

I've had a lot of requests from patients and personal trainers to write an article that encompasses the science behind how people injure their shoulders when weight training and also the specific elements behind my successful rehabilitation protocols, especially my unique application of clubbells to this problem.

In my experience, and that is a fair bit, the following article answers the problem for about 95% of gym related shoulder injuries.

There are, naturally, some exceptions to the following scenarios. I recommend that anyone who suffers from a shoulder injury does consult a knowledgeable physiotherapist, one who has experience in shoulder injuries in weight-trainers. I may be wise to give them a copy of this article for their professional library.

We will break this article into a series of headings

- USUAL SYMPTOMS
- ANATOMY
- TREATMENT

USUAL SYMPTOMS OF SHOULDER PAIN

Some of the first problems people notice are pain on movements such as Bench Press, Press behind Neck, maybe even Flyes and often dips.

These are usually the early stage problem exercises that are painful. People may complain that they are unable to sleep on the affected shoulder, that it can ache after long hours of sitting, that there may be pain reaching into the back seat of a car; these are just some of the common symptoms that manifest into more chronic shoulder injuries.

Where it hurts

There are two main areas people point to when I ask the "Where does it hurt?" The most common area people point to is the front of the shoulder, pretty much in the centre of the anterior deltoid.

For those of you with a bit more anatomical knowledge you might even recognise this as the area of the bicep tendon.

This leads me to explain why most people I treat have had unsuccessful treatment elsewhere. You see if someone pushes their finger into that point it is very painful, the person may then, mistakenly, believe it is a simple biceps tendonitis. But it usually is not, as I will explain later it is more commonly a referred pain from the infraspinatus muscle.

The next most common area people show me as painful is near to the area of the insertion of the deltoid muscle.

I'll let you into a little secret. Pain felt at the insertion of the deltoid muscle is usually referred from the supraspinatus muscle. This happens when impingement (pinching/squashing) of the supraspinatus occurs between the head of the humerus and the acromion process of the scapula. I'll explain that more clearly as we progress now to the anatomy section.

ANATOMY OF THE SHOULDER

In treating the most common non-traumatic shoulder injuries in the gym the main anatomical considerations are the bones and muscles, and this article is focused on these structures. Ligament and nerve treatment is rarer, and I may write on this another time. This is also not an article on A/C joint rehabilitation. so this article will concentrate on the bone and muscle relationships.

For the classic weight training shoulder injury there are two bones and one area of the spine that are usually involved. The scapula, humerus and thoracic spine. You need to understand the role of each one of these bones has to then be able to appreciate how the muscles relate to them. I'll only describe those areas that are related to this topic and leave the out the rest. OK.

Scapula

The scapula is triangular in shape, thus it has three borders. The main area of interest to us is the glenoid. This is the area where the head of the humerus sits to enable excellent, painless shoulder movement. The acromion is another important area as this is where the supraspinatus muscle sits below on the head of the humerus.

Humerus

The humerus is the long arm bone and it has a relatively larger golf ball shaped head. It is around the head of the humerus that the rotator cuff sits and works.

Thoracic Spine

Essentially, you have seven cervical (neck) vertebrae. Then the twelve thoracic vertebrae, finally the five lumbar (low back) vertebrae, this constitutes your true spinal column.

The thoracic spine is those twelve vertebrae that have ribs attached to them. Where each individual vertebra meets the above or below vertebra there are what are known as the zygapophyseal or "facet" joints.

Stiffness in these joints, and a lack of normal mobility, does affect the movement of the shoulder girdle quite significantly, this relates to the "missing" component in most shoulder rehabilitation programs. You should always ensure you have appropriate upper and mid thoracic mobility, and its component contribution to your pain should be assessed by a competent physiotherapist.

There are quite a few muscles involved in both the direct, and indirect, causes of shoulder pain. So let's go through them and outline their roles in shoulder movement.

Rotator Cuff

Everybody knows the words rotator cuff. The rotator cuff muscles are integral to the success of your shoulder rehabilitation. So let's meet them now.

There are four muscles in the rotator cuff. They are:

• Subscapularis
• Supraspinatus
• Infraspinatus
• Teres Minor

The aspect common to all these muscles is that they originate on your scapula and end up on your humerus. The main function of the rotator cuff is to act as a team to pull the head of the humerus into its best position on the glenoid of the scapula.

Briefly, when raising your arm, it is the supraspinatus muscle that begins the lift then, the deltoid takes over as its mechanical advantage is greater after 5° of movement from your side. During initial abduction (as this movement is called) the subscapularis, Infraspinatus and teres minor counteract the upward pull of the deltoid muscles, aided by the supraspinatus they produce a force that enables smooth, pain free movement as the arm raises.

Subscapularis

Is a large triangular muscle that fills the "subscapular fossa" (area on the front surface of the scapula). It attaches onto the lesser tubercle of humerus (on the front). Naturally then, the subscapularis rotates the humerus inward (internal rotation).

Supraspinatus

Is the muscle that originates above (supra) to the spine of the scapula. It then dives UNDER the acromion of the scapula to attach to the highest facet on the humeral head. It lifts (abducts) the humerus.

Infraspinatus

You may have guessed by the name that Infra means that this muscle originated INFERIOR to the spine of the scapula. It is large and occupies the "Infraspinatus fossa" of the scapula. This muscle attaches on the humerus in a way that causes it to pull in the action of EXTERNAL rotation.

Teres Minor

Hidden under the posterior deltoid and arising from a small area on the scapula border near the auxilla. It rises laterally with the Infraspinatus muscle to attach on the lowest facet of the greater tuberosity of the humerus. Teres minor passes behind the origin of the long head of triceps. Basically it acts as an external rotator and weak adductor of the humerus.

Well so that is the infamous rotator cuff. It is named as a cuff because it surrounds the head of the humerus like a cuff.

Now let's meet the other players in this show.

Rhomboids (Major and Minor)

Basically the rhomboids come from your upper and mid thoracic spine and attach to the edge of your scapula. What do they do? Well they hold your scapula in the best position as your arm moves. This is one of the most basic yet forgotten principles in shoulder rehabilitation.

Trapezius (Upper, Middle and Lower)
A big complex muscle that comes from the base of your skull and extends almost to your lower back. It has three parts, upper, middle and lower. They each have a role in rehabilitation and emphasis at different times of arm movement and loading.

Pectoralis Minor
Although far smaller than the pectoralis major, the most important of the pectoral muscles in shoulder injuries is the pectoralis minor. It starts at the ribs 3-5 and inserts on the coracoid process of the scapula. So, as I find in most cases, when it is tight it pulls the scapula forward and depresses the shoulder girdle by consequence. This alters the shoulder mechanics greatly and must be treated as part of shoulder complex rehabilitation.

Deltoids
Interestingly enough only worthy of mention in that they are major movers of the humerus. But actually play little or no real relevance in the cause or cure of problems in the shoulder area.

Yes there are other muscles in the shoulder girdle, but for 99% of the shoulder problems that occur in sports these are the ones that need to be addressed and balanced with strength.

Diagnosis
Let's roll the drums and stand in the spotlight now to "The diagnosis". I'll run this as a stream of thought for you. Similar to the way thoughts come to me as I diagnose a problem. Shoulder problems, without trauma, usually occur due to a problem with scapula control. So although you might feel pain in the front of the shoulder when bench pressing, it is felt there because the scapula stabilizing muscles don't do their job properly; as a result the rotator cuff muscles have to work harder to hold your humerus correctly as it moves under load, and then they hurt, and this sends a referral of pain to the area of the bicep tendon under the anterior deltoid.

Well that my friends, is a concise, condensed version of the problem. But I'm sure, if you study it closely, it makes sense and you can explain it to the next person you meet with shoulder pain in the gym.

Now the diagnosis is established it is time to begin treatment. What I will describe are the components that I instruct patients to perform. Naturally, there are parts within my personal assessments of each client that vary and there are techniques I may need to use, but in the main if you follow the protocols I'll outline you will save yourself a lot of pain and get back to training fast.

INITIAL TREATMENT (WEEK 1 AND 2)
SCAPULA AND HUMERAL STABILIZATION

BEGINNING POSTURE TRAINING

The basics are the most important part of the whole program. Follow me on the anatomy. Since these problems are caused by poor scapula stability, this is where we start. It is a fact that nearly all shoulder problems are caused or perpetuated by poor posture. You see people sitting over their computers for hours at work with shoulders hunched over, and then these same people go to the gym and grind out endless sets of Bench Press. It is just trouble waiting to happen. The first thing a person should do to help resolve their pain is to learn to sit with their shoulders uncomfortably pulled back. This posture is produced by contraction of the rhomboids, middle trapezius and slightly the lower trapezius. It also therefore stretches the pectoralis minor.

The plan is to sit in such a way that you are uncomfortable and that you are aware of using your middle trapezius and rhomboids to do the work. Now the next part is to put a reminder in your computer appointment schedule that will pop up each hour to remind you to sit tall. This is as effective as if I, personally, ring you up hourly and tell you to do that. This is most important over the first two weeks of the program. It is hard work but you are beginning to build endurance in those scapula stabilizer muscles.

OK now let's talk philosophy. My weight training philosophy. I prefer real weight training eg. Dead lift, squat, bench press, snatch, clean and press, clean and jerk, dumbbell or barbell standing presses, dips, chin-ups, kettlebell and clubbell versions of the above, kettlebell and Clubbell swings. Whatever your fitness or aesthetic goals these exercises and their variations will be the most effective ways to achieve strength and physical change.

That said, I then recognize that other movements and machines may be used in a rehabilitation setting. I find no reason to use a machine unless it is to work around an injury. If you wish to keep muscles working whilst injured then the machine/equipment may be necessary.

WEEK 1

In the Gym

You need to know what exercises you can and cannot perform. Clearly leg training should be fine. Some people find squatting is painful due to poor shoulder flexibility at this point. If so then find alternative leg work until you can. I like people to begin back training as well. Basically a rowing motion or variation of rowing, often underhand grip with an emphasis on pulling the scapula together in the motion. Tricep training may be restricted to pushdowns or dumbbell kick backs. Abs obviously shouldn't be a problem. That is about all you can do in resistance training at this point. Cardio is your choice, without shoulder pain naturally. Begin Shoulder Rehabilitation Exercises.

To perform this exercise properly you lie with the painful shoulder uppermost. Pull your scapula towards your spine, preferably depress and retract. If you get this right your upper trapezius should be relaxed while the middle and lower fibers of trapezius are stabilizing with the rhomboids. Perhaps think of using your lats to pull your shoulder down, Keep your elbow by your side and rotate your arm as shown. Generally I use a 2kg Clubbell for a normal adult. Repetitions between 12-25 are used to produce neurological skill and endurance control. 2 sets per session performed 2-3 X per day. Perform this exercise on both shoulders as there is a learning cross over from your uninjured shoulder that teaches the injured shoulder how to correctly perform the movement pattern.

The next two images demonstrate the versatility of the clubbell in this exercise. As you progress you can alter the leverage according to where you hold the clubbell. This enables you to work with varying loads and challenges your stability, especially good as pre-hab once your problem is resolved and you are using heavier clubbells.

Week 2

In the Gym

We continue with week 1 routine but now you can try to find a bicep movement such as concentration curls which by relative "isolation" may not produce pain in the shoulder when it is performed.

Special Exercise 2: Horizontal extension in prone.

It is important to continue with external rotation in side lying. We now plan to add a second movement. You perform this exercise lying face down on the floor, your arms out from your sides as if imitating a flying aircraft. With your clubbells held in your hands you lift your arms off the ground, about 10-15 cms is fine, then return to the ground as per exercise 1. Use 2kg to begin, repetitions between 12-25 2 sets per session performed 2-3 X per day.

The variation of this I use is to bend the elbows 90° and perform the horizontal extension from that position. Often I prescribe both versions of horizontal extension.

Why do I perform this exercise on the floor and not off a bench? Due to mechanical advantage! In the floor position the rhomboids and middle trapezius have a mechanical advantage to retract your scapula. Whereas if you do this off a bench, the deltoid and triceps will extend your humerus in domination of the scapula retraction movement. Let me name this "Lock's Law of the Blatently Obvious".

Once again you can change the leverage in this exercise to make it harder as a pre-habilitation movement.

WEEK 3

Training now becomes more normal. By week 3 I begin to implement the clubbell exercise: 2 hand flag press. This is vital to perfect. Those people who want to master the bench press will be thrilled at the benefit of the 2 hand flag press. Vital, there can be no more apt word to describe the application of the 2 hand flag press to the bench press. You learn to retract and depress your scapula, as you did in the side lying external rotation exercise, but obviously you are standing. If you have this standing posture correct then your upper trapezius will be relaxed. Your lats will be tight. Your chest will be arched. Then you begin your press. This will mean you are keeping your arched chest by using your scapula stabilizers then using your lats and pecs to co-contract to stabilize and move your humerus under load.

The 2 hand flag press teaches the necessary scapula and humeral stabilisation better than any other exercise. Naturally your rotator cuff must co ordinate the humeral control with this centre of mass movement challenge as presented by the clubbell.

Remember, in the two handed flag, the upper trapezius must stay loose the whole time during the press.

As a result from learning the 2 handed flag press, you can now transfer this skill to the actual Bench Press itself. You can begin back on the Bench. No pain allowed, just practice your skill DAILY when you are in the gym. You are not to go to fatigue, keep Bench reps under 5. Sets 3-5.

Special Exercise 3: The Butterfly

Should you be progressing as normal then I usually dispense with side lying external rotation and horizontal extension and introduce the Butterfly. The butterfly is so named because it resembles the butterfly stroke in swimming and since I invented it I get to mane it. We start the exercise in the horizontal extension straight arm position, lift upwards then slowly reach forward overhead, Stop. Then place the clubbells down. Then lift up and return slowly to the starting position. You should perform slowly in control, not letting your hands or club touch the ground during the movement phases. 1 repetition is counted when you have performed the movement from start position and returned to the start position. If 2kg is too heavy you may need to start with 1kg or even no weight at all. Repetitions here are likely to be 5-10. 2 sets, 2-3 X per day.

WEEK 4

Well if all is going to schedule you are now allowed to test any exercise you wish in the gym, except the clean and jerk, snatch, and dips. These you can begin to examine next week.
You should now be doing the Butterfly daily, and Horizontal Extension daily. You can do the Side Lying External Rotation just twice per week for life. As you improve over the weeks you then treat the Butterfly and Horizontal Extension exercises as you would any other part of your routine. The same goes for the 2 handed flag.

Final Note

So this article covers the basic approach I use from clubbells in shoulder rehabilitation. Every person I treat in my office obviously gets individual assessment that may vary as I see appropriate. But these basics above will work in most cases for resolving resistance training pain of rotator cuff involvement.

P.S. I am often asked about the solution to Winging Scapula problems, so here is the clubbell answer.

Winging Scapula

There is no more effective exercise to combat serratus anterior weakness (winging scapula) than the torch press exercise with a clubbell. My patients routinely improve more in 2 months of clubbell pressing training than their counterparts did in 10 months of traditional exercise protocols.

The serratus anterior activation, especially the lower fibers, required to control the scapula in a torch press cannot be replicated effectively by any other equipment or machine. I prefer the single hand torch press for this, the weight is naturally less than you use in the two handed torch press and it requires the independent control relationship between scapula stability and clubbell.

When the patient reaches a level of competence and I believe them to be ready I then progress to 2 clubbells and doing torch press with each arm concurrently. This increases the shoulder stabilisation mechanism especially with the middle and low trapezius fibers. Remember this is solely how I approach winging scapula issues with clubbells. I use other variations of the torch press for other issues.

Winging scapula is rarely seen in weight training populations due to the amount of pressing movements they perform. But there are people who display this condition and it should be treated. Snapping scapula syndrome is also best approached from a clubbell perspective but I shall write these protocols at a later date

Looking at the picture below you can see how the inferior angle of the scapula, which is controlled by the lower fibers of the serratus anterior, is held close to the chest wall in this exercise.