injury & REHAB
why does bad shoulder posture lead to injury?
Poor shoulder posture, leading to injuries, can’t simply be remedied with the old advice to ‘pull the shoulders down and back’.
How many times have you heard the advice to ‘Fix your posture by pulling your shoulders down and back’? I’ve heard it said on countless occasions by parents, personal trainers, gym class instructors and healthcare professionals. In many instances, however, this advice is incorrect.
Many clients in our physiotherapy clinic have been referred to us by their gyms after following instructions to pull their shoulders back while doing simple resistance work with free weights or participating in weights-based classes. This action can cause more damage than good, as muscles the individual is not used to using, specifically the upper trapezius and rhomboids, are over-recruited and become fatigued. This leads to muscular spasms and associated neck pain and reduced movement. It’s a common occurrence in those returning to the gym after a period away.
Everyone’s posture is different, so when addressing this issue it should be taught on a one-to-one basis and fully explained to the client so they understand how to address and change their posture to reduce risk of injury and pain and to improve performance. Pulling the shoulders ‘down and back’ and fixing them there is not a sustainable posture.
Good posture is a position you are able to maintain: it is where the body is most efficient, whether it be a static position or a dynamic movement. The body should be neither tense nor loose. It might take a little effort sometimes to correct your posture, but it shouldn’t actually be difficult. Your shoulders sit where the sum of the forces of gravity, your soft tissues (muscles and ligaments) and your bones put them.
|The 30-second article|
Why is poor posture so common?
Most people’s shoulders sit forward because of western lifestyles – long periods sitting in front of computers, using smartphones, watching TV, driving, stress and anxiety. These activities result in a forward shift of the humeral head, a protracted neck and flexed thoracic spine. Over time the pectorals get shorter and tighter, while the scapula-stabilising muscles become long and weak. This can cause reduced rotator cuff strength and stability, increased loading through the anterior structures at the glenohumeral joint, and dysfunctional scapula movement. The cycle becomes perpetual.
Most physical activity and exercise that takes us out of these postures is beneficial. Injuries occur, however, when people start performing high intensity exercise and high level movement patterns without sufficient knowledge, fitness and physical preparedness. In other words, when they go too hard too soon.
When clients do technical and high intensity exercises, such as kipping pull ups and overhead presses/squats, they are heavily loading an unstable and biomechanically inefficient joint. This, in turn, causes loading through the biceps insertion and glenohumeral joint. It’s not surprising, therefore, that pain and injuries can result.
Not perfect, but pain-free
How many of your clients have perfect posture? None – there is always something that can be improved. It’s unlikely that they will ever achieve perfect posture, but by providing clients with guidance, you can help put their bodies in a pain-free and mechanically advantageous position for the tasks they regularly perform.
Posture is a position that your clients need to be able to maintain or get into time and time again, whether it be for everyday activities or for exercise and sport. Initially, they need to be taught the correct way to do this, but unless you are paid to follow them around for the rest of their lives, they will need to be able to modify it themselves.
One way to encourage them to do this is by telling them to follow these steps:
- Choose a movement/position or activity that you find causes pain or stiffness, e.g. rotating your head/lifting weight
- Note the amount of effort it takes to perform this movement or task
- Try to correct your posture to what you think is a better position
- Re-test the movement and again note the amount of pain, stiffness or effort it takes to perform
- Note whether it is easier or less painful. If so, you are in a better posture for performing that task. If not, it’s not quite right for you.
What does the research say?
The shoulder joint is known for its huge amount of multi-planar mobility (enabled by the shallow socket in which it sits) and generally poor stability. It is held in the socket largely and foremost by the muscular unit surrounding it.
The results of studies into shoulder pain experienced by gymnasts can be extrapolated to some CrossFit gymnastic movements, such as the kipping pull up. One study looked at swinging forces through the shoulders in gymnasts and speculated that delayed timing of muscle activation as a result of poor technique could lead to a SLAP lesion (superior labral tear from anterior to posterior) in the shoulder. This injury is commonly seen among the CrossFit community and occurs when there is repetitive and excessive loading through the glenoid labrum and long head of biceps tendon, which results in a glenoid labrum tear. It has been hypothesised that this occurs at the bottom of the swing, at which point muscle activity is low and subsequent stress through the non-contractile structures such as the labrum and ligaments is high. This, coupled with large biceps tendon tension, could increase risk and certainly cause SLAP lesions, especially when performing numerous reps during an AMRAP (as many rounds/reps as possible) workout. The study authors suggested that the athletes, in order to pre-hab themselves, should do proprioceptive training so that they could recognise the correct position of the humeral head in the glenoid fossa.
What other factors cause shoulder injuries?
Fatigue and flexibility also contribute to the high volume of shoulder injuries incurred by everyday fitness clients.
When the body gets tired, it loses form when performing a movement, as the body takes the path of least resistance. This means that as the muscles surrounding the shoulder joint get tired your shoulder position will be compromised.
Lack of flexibility is a very common problem, with many people having tight pectoralis minor and major, latissimi dorsi and upper trapezius. As these muscles are used in pulling, pushing and overhead movements, they experience a large amount of overuse. When these muscles are tight they worsen the kyphotic thoracic spine posture, making it difficult for the individual to put their arms overhead without extending through the thoracic spine. This means that at the end of the range of the movement, i.e. when you are hanging and swinging under the bar, you are performing an end of range stretch against your whole body weight, which is a huge load to put through the joint. In addition to this, reduced flexibility results in inhibition and weakening of the scapular stabilisers, such as the lower trapezius and serratus anterior.
What can we do to prevent injuries?
Encourage clients to have a postural assessment with a good physiotherapist, and have their general posture and flexibility assessed.
Heighten your awareness of clients’ form and exercise technique. If they experience pain or discomfort, they are probably doing something wrong and are at risk of injury. You need to help them create a strong foundation on which to build.
Educate clients about working on their mobility and soft tissue flexibility (daily if possible), through the use of sustained passive stretches to the latissimi dorsi, pectoralis and upper trapezius, and maintain thoracic spine mobility. Use trigger point and myofasical release tools such as spikey balls and foam rollers.
Incorporate rotator cuff strength and control exercises to clients’ programs. These exercises should be performed at varying degrees of shoulder abduction. Using theraband or tubing will also improve their motor control.
There are many benefits associated with high intensity training, but they may be short-lived unless the participant works to improve their posture, strength and flexibility prior to getting started.
Jenny Doyle MSc (Hons) is a physiotherapist and sports scientist with extensive clinical experience, and is also a massage therapist and clinical Pilates instructor. She works with Active Anatomy Physiotherapy which runs health professional rehabilitation workshops across Australia. activeanatomy.com and 02 9451 9014.