Subacromial Impingement Syndrome is probably the most common injury I see in the clinic. It’s definitely the most common source of shoulder pain I see. Often times it’s associated with:
Subacromial impingement syndrome is also associated with instability of the shoulder and is probably worsened by acquired looseness from things like labral tears. Even if you don’t have a full blown injury most people end up with sore shoulders from time to time in the gym. Since it’s so prevalent, I wanted to make an article series talking about what I believe are the most common reasons for this. We’ll be breaking this mammoth up into a few parts. Without further ado:
The first thing to understand when it comes to performing a lot of resisted pressing (push press, bench press, jerks, pushups, dips, handstand pushups) is something called a force couple. When I bring my arms overhead (especially under load) the deltoid is very active in allowing this motion to occur. As the deltoid fires, the rotator cuff also has to fire simultaneously in order to keep the ball centered in the socket. As you can see in my “beautiful art work” below, the deltoid (D in red) imparts a superior or upward force on the shoulder joint when it is activated. The rotator cuff (RC in green) imparts a force to help pull the ball into the socket.
Now, if the deltoid overpowers the rotator cuff you end up with a net “superior” or upward force in the shoulder joint. In subacromial impingement syndrome the rotator cuff ends up getting compressed partially due to this scenario.
Think of all of the pressing movements that directly stress the deltoid:
This is the reason why having a super strong rotator cuff is imperative to shoulder health. Our cuffs need to have the capacity to handle all of the stress of our workouts and help to minimize movement within the shoulder joint. There’s currently a lot of hatred out there toward rotator cuff strengthening. It’s obviously just one piece of the puzzle but it’s an absolute must for shoulder health.
So we just went over the force couple idea that occurs within the shoulder during pressing. Every time we press something overhead the subacromial space is decreased. This means the cuff, biceps tendon and bursa all get compressed. Now, with better cuff strength and better scapular positioning we end up stressing the rotator cuff tendons less. However, every time we press the area still takes some heat.
Now, it stands to reason that our bodies can only handle so much stress. What I end up seeing are people that are just performing way too much pressing volume. When our program seeks to improve olympic lifts and strict gymnastics and uses things like wall balls and burpees as a conditioning tool we can end up stressing the cuff 5 or more times per week. That’s a mighty task you’re asking of some relatively small tendons.
What I think is important is that when coaches are programming for the week, month and year they need to take into account how much total volume of pressing movements are in the mix.
Every wonder why when you have shoulder pain it generally feels good to perform rowing movements (dumbbell rows, lat pull-downs, strict pull-ups) when pressing just hurts? Let’s go back to the force couple idea:
So when we press overhead the middle and anterior deltoid are being used quite a bit for the movement. When we row these muscles are relatively quiet. On the flip side of the equation when we row the lats are very much involved as prime movers for the exercise. Now, from the orientation of the diagram below you can see that when the lats contract and shorten, it actually causes a downward force of the ball in the socket. This actually increases the subacromial space and can unload the rotator cuff, bursa and biceps tendon.
Also, when we train rowing movements not only is this helping to unload the cuff tendons but also builds the important scapular stabilizers. There is quite a bit of research out there to support training these muscles to help reduce shoulder pain.
4) Spikes in training volume (sudden increases in total shoulder intensive training)
Some recent research from Tim Gabbett has shown us that in professional Rugby and Soccer players that if we have spikes in training volume it greater increases our risk of injury. I really don’t feel like it’s any different in the gym. As a physical therapist I see this all of the time. It can happen within a single session, within a week or over an even longer period of time. Here are a few examples from athletes I’ve treated.
My shoulder pain started after the workout, “Randy” performing 75 snatches for time.
Well on Monday I hit a pretty intense overhead pressing workout. On tuesday we had handstand pushups in the workout. Wednesday had quite a few pushups in the mix. Thursday came around and there were a bunch of burpees. Friday my shoulder was really bothering me and I figured I should quit.
1 month ago I started doing handstand pushups twice per week because I really wanted to get better at them. About 3 weeks into this my shoulder really started hurting.
We need to make sure that we’re making smart training decisions on a daily, weekly and monthly basis. Any spike in volume can leave us hurting.
So we’ve finished up 4 principles, next article we go over 2 more to help you with your shoulder issues. Stay tuned until next week.
Want to learn more about shoulder impingement and rotator cuff injuries as well as how to rehabilitate back from them? This short video is part of a larger and much more comprehensive educational course and rehabilitation training program on rehabilitation from shoulder injury called “Ultimate Shoulder.”
“Ultimate Shoulder” is a 12 week training program to help you fully understand and rehabilitate back from shoulder injuries:
Pumped for the next installation,
Dan Pope, DPT, CSCS, OCS, CF L1
How to Train With Knee Pain (Part 1)
Can We Predict Who Will Get Hurt Doing CrossFit (TM)?
How Often Should You Train to Get Stronger Without Getting Hurt?
4 Easy Ways to Modify Bench Press and Overhead Press in Athletes With Shoulder Pain
Keys to Fix and Prevent Shoulder Pain
Shoulder Impingement Part 6: Do You Have Shoulder Impingement?
Shoulder Impingement: Part 4 – The Thoracic Spine and Ribcage’s Role in Impingement
Shoulder Impingement: Part 2 – What Happens at the Shoulder Joint During Impingement