// Common injuries: 5 tips to save your shoulders
by Paul Wright
Shoulder pain is one of the most common problems treated by physiotherapists and sports physicians, and is particularly common in those who participate in health and fitness-related activities.
In past articles I have talked about some of the most common conditions that we see related to the shoulder, including referred pain, dislocation and impingement; however, in this article I will give a more general overview of the recommendations we make to our physiotherapy clients to assist in the prevention of shoulder related injuries.
Anatomy and physiology
In basic terms, the glenohumeral joint (the joint between the humerus and the glenoid fossa of the scapula) is a multi-axial ball and socket joint that allows an amazing degree of movement. However, this freedom is achieved at the expense of stability and security and is often the cause of many dislocation and instability-related issues.
Due to the relatively shallow socket provided by the scapula, the glenohumeral joint requires support and assistance from other structures to improve stability. These support structures include the glenohumeral ligaments, glenohumeral joint capsule and a thin rim of fibrocartilage around the glenoid called the glenoid labrum. These support structures assist in keeping the humeral head in contact with the glenoid fossa during movement of the shoulder joint; however, they do not prevent dislocation.
The glenohumeral joint is supported and controlled by four small muscles that make up the rotator cuff group – these are the supraspinatus, infraspinatus, teres minor and the subscapularus. These small, but very important, stabilisers are easily overloaded and injured due to poor program design or exercise technique. Many of the following injury reduction techniques focus on reducing the load on these small joint stabilisers.
Tip 1: Limit overhead exercises
Many gym training programs involve extensive overhead pressing movements. Intensive overhead movements are often overrated and can lead to shoulder problems.
When you look more closely at the available range of motion in the typical military press, at the start of the movement the shoulders are already in 70 to 80 degrees of abduction, and, depending on the width of your grip, at the end of the pressing phase you may only be at 130 to 140 degrees. This equates to a movement of only 60 degrees at most. If you subscribe to the ‘time under tension’ philosophy for hypertrophy, then it stands to reason that this reduced range of motion will reduce available ‘tension time’ and, thus, reduce results.
A better and more shoulder-friendly exercise is the closer grip barbell shoulder press, dumbbell shoulder press, or Arnold press, in which the movement begins lower down and follows a flexion/extension plane rather than the abduction/adduction plane. This allows a greater range of motion but also keeps the hands closer to the centre of the body and reduces shearing forces around the shoulder.
Tip 2: Beware of the dislocation position
A common test when evaluating shoulder joint stability is the Apprehension Test. This involves laying the patient supine with the humerus at 90 degrees of abduction, and then slowly externally rotating the humerus until the patient becomes ‘apprehensive’ – this is most often seen when the patient grabs you by the throat with the healthy hand and tells you to stop!
The patient becomes apprehensive because they feel that the shoulder joint is becoming unstable and may dislocate if taken any further into external rotation. This test reveals to us that the dislocation position (and apprehensive position) is in abduction and external rotation.
Exercises which place clients in this dislocation position include press behind the neck, rear wide grip pulldowns, 90/90 pec dec machines, and many shoulder press machines – particularly those with the seat well in front of the actual handles.
To reduce stress on the shoulders, eliminate exercises that place clients in this position, especially machine-based versions, as the machines are less forgiving and force the adoption of positions that the body cannot adjust to. Dumbbells and cables are less constrictive, so provide more freedom.
A final tip that helps test whether the dislocating position has been reached is whether or not the hands can be seen throughout the entire duration of every exercise.
Tip 3: Beware of small muscle overload
It is easy for the stabilising muscles to be overloaded, especially by those who do hard gym training three to four times a week. These small rotator cuff muscles are easily fatigued if you do a routine such as chest on day one, shoulders on day two, and back on day three; even though it seems that you are only doing shoulder exercises on one day, the actual shoulder muscles are involved in all of these workouts.
I recommend that more advanced trainers group the pressing movements into the same workout and never do shoulders as a stand-alone body part. The deltoid group as a whole will get plenty of training effect from a solid chest and back routine so they will rarely, if ever, require individual and intensive training.
Be especially aware if you and your clients are involved in other shoulder-related activities such as tennis, swimming and surfing, as these activities will also drain your recovery powers and lead to overloading of the small stabilisers.
Tip 4: Increase thoracic spine mobility
I am yet to see a shoulder-related problem that cannot be at least partly eased by the introduction of exercises to increase the mobility of the thoracic spine. The thoracic spine plays a significant role in loading (or unloading as the case may be) the glenohumeral joint.
I encourage all trainers to include a basic thoracic spine mobility test in all their pre-exercise screenings. One of the simplest tests involves asking the client to sit on the edge of a bench and raising both arms as far as possible over their heads. If the patient cannot reach at least 170 degrees of shoulder flexion they should not be given overhead exercises. It is clear to see that this reduced range of motion would lead to massive stresses being placed on the glenohumeral joint during most overhead pressing exercises.
It is also important to include exercises which encourage thoracic extension and rotation in all training programs. Some of my favourites include ball pullovers, one-arm dumbbell rows and standing one-arm cable rows.
There may also be some limitation in techniques for sports practiced by your clients that need to be addressed in their sports coaching sessions. Some examples of sports technique modification to reduce shoulder stress include increased body roll in freestyle swimming (again requiring thoracic spine mobility), modification to the ball toss in the tennis serve, and improving the follow through in cricket fast bowlers.
Tip 5: Keep out of the impingement position
If abduction and external rotation is the ‘dislocation position’ then abduction and internal rotation can be described as the ‘impingement position’.
Impingement is the term given to describe the ‘pinching’ or ‘jamming’ of tissue between the acromion (the end point of the scapula) and the humerus. This jamming usually occurs as the arm is abducted at the shoulder and is especially evident when the humerus is internally rotated. Chronic impingement can lead to a swelling of the affected tissues and a further reduction in the size of the space between the acromion and the humerus (this space is referred to as the sub acromial space).
Common exercises that place the shoulder in the abducted and internally rotated position include the upright row (especially with close grip and high pull positions), lateral raises with thumbs to the floor and some barbell bench press techniques – especially with the a high bar position almost under the chin.
The shoulder joint is a joint that can easily be overloaded and damaged in poorly constructed health and fitness programs, so it is essential that the health professional understands the anatomy, physiology and common risk areas and exercises. Take particular note of the abovementioned points if your client has any past history of shoulder pain or pathology, as past history of injury is the biggest single indicator of injury risk in the exercising population.
Paul Wright, BAppSc (Physio), DipEd (PE)
Paul is the owner of Get Active Physiotherapy with clinics inside Fitness First clubs at St Leonards (Sydney) and Kotara (Newcastle) and can be contacted on 1300 891011. His DVD range (including a session on Shoulder Injury Rehabilitation and Injury Prevention for Health Professionals) can be previewed and purchased at www.getactivephysio.com.au. Paul has also recorded a CD titled How to Increase Profits from your Health Business, which all Network members can access for FREE at www.healthbusinessprofits.com/freecd
NETWORK MAGAZINE • WINTER 2010 • PP46-48