Why Does Pressing Hurt the Shoulder but Not Pulling?

In the past article series on why shoulder injuries are occurring in the gym we talked a bit about the rotator cuff and it’s importance for shoulder health.  The rotator cuff serves as a dynamic stabilizer of the shoulder joint.  In other words, as the shoulders moves around to perform things like push press, bench press and pull-ups the rotator cuff helps to stabilize the humeral head (ball) into the socket (glenoid).

Rotator cuff (from behind)

I like to think of the rotator cuff as a sling that hugs the ball into the socket in the shoulder joint.

 

Now, the theory is that if we don’t have good dynamic stability from the cuff then the ball ends up moving (gliding) and when it glides superiorly can compress itself (The rotator cuff), the subacromial bursa and the long head of the biceps tendon.  For more information about this (subacromial impingement syndrome) I’ve written a lengthy article on the subject in the past HERE. 

Rotator cuff (from the front)

Now, when people are having shoulder pain (and more specifically subacromial impingement syndrome) you may have noticed that pressing exercises generally increase pain levels, where as rowing exercises won’t.  Patients will say they can’t bench press or press overhead but pull-ups and other rowing exercises are generally well tolerated.  What gives?

Well, it comes back to the concept of force couples that we spoke about in the last article series.  In overhead pressing exercises the deltoids are very active.  They help propel the load overhead.  Not only do the deltoids help raise the arms overhead but they also impose an upward force on the shoulder joint based on their origin and insertion from the shoulder blade to the humerus.

On the flip side of the coin the rotator cuff (in this case the supraspinatus muscle of the cuff) helps to pull the ball into the socket during an overhead press.  If the rotator cuff is overpowered by the deltoid or if the timing of the rotator cuff is delayed you can see with the image below how the ball will be pulled upwards (superiorly) in the socket.  Unfortunately this ends up compressing the rotator cuff, subacromial bursa and long head of the biceps.  Too much of this is theorized to cause tendon problems like tendinitis, tendinopathy and tears.  This is the term known as subacromial impingement syndrome.  With these concepts in mind it makes total sense that pressing overhead hurts when you have this condition.

So what about pulling exercises?  As the title of the article implies how come pulling exercises like a row tend to be pain free when a press hurts?  Let’s take a look at our force couple example again.  As we discussed during an overhead press, the deltoids are very active and exert an upward force on the shoulder joint, potentially compressing the rotator cuff.  When we do a pulling variation like a pull-up, the muscles used are different.

When we do a pull-up, the deltoid is relatively quiet.  Instead the shoulder extensors are very active (Thinks muscles like the lats and teres major) to help pull our chin over the bar.  Now, check out the direction of pull of the Lats in the diagram below.  The lats actually impose a downward force on the humeral head during a pull-up.  What this means is that the lats are helping to depress the humeral head and decrease compression of the rotator cuff.

Now, if you have an aggravated rotator cuff.  Let’s say you have either a tendinitis, tendinopathy or full blown tear that’s symptomatic.  It makes sense that the movements that cause more compression on the tendon are more painful.  Hence why pressing hurts where pulling feels alright and potentially helps.

Side Note: The current thought in our medical literature is that a combination of compressive and tensile load is causing tendinopathy.  In overhead pressing the supraspinatus tendon is very active and also has the potential to be compressed.  This mixed loading is thought to be the driver of rotator cuff issues.  

One of the first things I like to do when people have shoulder pain is to modify the activities that are creating pain.  For many this is pressing.  I substitute in more pulling movements, rotator cuff and scapular stability exercises in their place.  Here are a few ideas for you:

more goodies…

So the next time you’re experiencing some shoulder pain try this out:

  1. Replace painful movements with pain free exercise variations shown above
  2. Get on a solid rotator cuff strengthening program
  3. Add in some additional pulling movements instead of pressing
  4. Slowly reintroduce pressing movements again once pain has subsided starting with easy lighter variations and progressing to harder heavier loads

Depending on the shoulder issue, the individual, how long they’ve had the pain and what you want to get back to this could take anywhere between a few weeks to several months.

In case you haven’t realized it, I’ve been on a shoulder kick lately.  This is because Dr. Dave Tilley from shiftmovementscience.com and myself have been working on a big new shoulder product to help physical therapists, coaches and athletes get out of shoulder pain, back to level high levels of performance and to stay pain free for the long run.  Sign up below if you’re interested in being notified when the product comes out and to receive a special discounted offer.   

I’ve got another fun one brewing for you next week,

Dan Pope DPT, OCS, CSCS, CF L1

References:

  • Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46(3):163–168. doi: 10.1136/bjsports-2011-090414. [PubMed] [Cross Ref]
  • (SEITZ A., McCLURE P., FINUCANE S., BOARDMAN D., MICHENER L.; Mechanics of rotatot cuff tendinopathy: intrinsic, extrinsic, or both?; ‘http://www.clinbiomech.com/article/S0268-0033(10)00221-4/fulltext’; 16 september 2010, clinical biomechanics. Level of evidence: 2C Level: 2C,
  • LEWIS J., Rotator cuff tendinopathy: a model for the continuum of pathology and related management; ‘http://bjsm.bmj.com/content/44/13/918.long’, Br J Sports Med 2010;44:918-923 doi:10.1136/bjsm.2008.054817. Level of evidence: 2C level: 2C)

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