Build Resilient Shoulders to Prevent Shoulder Pain

As a coach or trainer, most of you have had to manage clients with shoulder pain.  The shoulder is a complex area and shoulder pain and dysfunction is common, especially in activities that involve overhead work.  What if I told you shoulder impingement is normal?

One aspect that is important to keep in mind when dealing with shoulder pain is that the shoulder naturally impinges every time we move into an overhead position.  Shoulder impingement is a natural physiological process.  We talk about a subacromial space, but there isn’t actually any space.  The subacromial compartment is tightly packed and anything that can further impinge that space even slightly is likely to cause problems.  Consequently, there isn’t any room for error, pardon the pun.

 

shoulder joint anatomy

 

Problems with shoulder impingement or impingement syndromes, can occur in different ways.  Primary shoulder impingement can be due to morphology of the acromion.  Individuals with a Type II (curved) or Type III (hooked) acromion are at greater risk for subacromial impingement, as are individuals with degenerative spurring on the undersurface of the acromion from years of wear and tear.

Problems with shoulder pain can also occur when an individual increases the frequency at which they move into overhead positions.  Take for example a previously sedentary individual who starts CrossFit.  This individual will go from relatively little or no overhead work in activities of daily living to pull-ups and overhead presses performed 2 to 3 days per week, or more.  This acute onset of overhead work can lead to acute impingement and shoulder pain.

Whether there is a structural abnormality, which we cannot control, or a sudden onset of overhead work, which we can, one thing remains certain.  We need pristine shoulder mechanics if we hope to prevent excessive impingement of the rotator cuff underneath the acromion that is likely to cause shoulder pain.

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PRISTINE SHOULDER MECHANICS

When we talk about pristine mechanics, we mean everything that can have an effect on getting the shoulder into an optimal overhead position.

The scapulohumeral joint

It is scapular function that mediates optimal function of the shoulder (glenohumeral joint).  Appropriate scapular movement requires soft tissue integrity. Overhead movement requires upward rotation and posterior tilting of the scapula, which can be limited by a hypertonic pec minor and levator scapula.  Tightness in the lats, pecs, rhomboids and posterior capsule of the shoulder can also limit overhead movement.  All these need to be assessed and addressed.  The serratus anterior and lower trapezius are the drivers of scapular posterior tilt.  Exercises that help target these and bring awareness to the position of the scapula must also be included to optimize scapular function.

The thoracic spine

Full elevation of the shoulder requires extension and rotation of the thoracic spine.  Limitations in thoracic spine mobility prevent the scapula from attaining or maintaining an appropriate position for overhead work.

You can use the Standing Shoulder Flexion test to screen for these functional requirements for overhead work.  To know what to look for in this test, head to the video article A Must for Shoulder Assessment.

The cervical spine

The position of the scapula can also be influenced by the position of the cervical spine. Several studies show that anterior projection of the head increases the anterior inclination of the scapula during elevation movements.

Is there forward projection of the head? Is range of motion complete?  You can clear the cervical spine to see where there are opportunities to optimize movement.  Here’s what a quick range of motion screen would look like:

Flexion: Can they bring the chin to 1-2 fingers widths from the chest? Can they look to the waist or feet without flexing the torso forward?

Extension: Can they bring the forehead to 10° from parallel?  Can they look towards the ceiling without extending the torso of flexing the knees?

Rotation: Does the tip of the nose align with the mid-clavicle?  Can they look towards the shoulder without rotating the torso?Level 2 banner

 

 

STRENGTH FOR RESILIENCE

Even with all the appropriate mobility and stability, we can still run into problems with overhead movement if we lack strength and endurance in key positions.  You need strength for robustness and resilience.

A robust tissue can tolerate more load without deformation.  It can tolerate higher loads without giving.  Think of a bullet bouncing off a bulletproof window.  From a training perspective, think of the body’s ability to handle high loads.  A resilient tissue can bend without breaking.  It can tolerate deformation and return to its function unscathed.  Think of a palm tree bending with the wind and standing straight on a windless day.  From a training perspective, think of the body’s ability to handle loads applied differently.

 

         

We know that loading tissues creates a predictable response within a predictable range.  When tissues are under-loaded, such as via immobilization following injury or by decreased movement variability, stress tolerance decreases.  On the other hand, if we progressively overload tissues, stress tolerance increases, but without the overload, no significant changes in tissue tolerance occur.  Of course, if we exceed tissue tolerance or adaptive capacity; if overload is excessive, repetitive or biomechanically inefficient, injury occurs.  This is typically what we see in cases of acute shoulder impingement.

If we hope to increase the shoulder’s tolerance for overhead work and the physiological impingement that comes with it, we need overall strength as well as strength in key positions.  We need to progressively load tissues in specific positions to build load tolerance, robustness and resilience.  This is what we call stress-induced tissue resilience.

 

CONTROL-ENDURANCE DRILLS

Control-endurance drills are exercises we use in the Activation phase of our programming, or even in the Integration phase.  They could be used in the warm-up of a shoulder workout.  To learn more about how we program Mobilization, Activation and Integration in a warm-up, head to the video article: How to Build a Warm-up That’s Actually Useful.

The idea behind integrating control-endurance drills for the shoulder is that introducing low-dose stress induces conditioning of tissues making them resilient in the face of subsequent stress.  I also particularly like these drills because they bring awareness to scapular movement and function for upper extremity function.

The first drill is the scap stepdown.  This exercise can be performed on a plate or step (something about 3 inches high or so).  In the starting position, both hands are level with one hand on the plate/step and the other hand is un-supported.  Let the scapula retract to lower the non-support hand till it lightly contacts the floor and then press away with the support hand to resume the initial position.  We will do this using a slow and controlled tempo of 3 seconds down and 3 seconds up. I typically use 1 set of 12-15 reps progressing towards 20 reps.

The second drill is the overhead scap press or shrug.  In the starting position, the arms are in a full overhead position.  The shrug is more of an over-reach than a “trap-to-ears” shrug: reach up towards the ceiling with the fingers such that you are pushing the scapula into further upward rotation, then slowly return to the starting position.  On the return, you also want to be careful not to squeeze the shoulder blades down, just letting them return to the full overhead position.  Use the same sets and reps as for the scap stepdown.

Don’t forget to watch the full video to see how the control-endurance drills are performed!

 

SPECIAL CASES: TENDINOPATHY

In cases of rotator cuff tendinopathy, I have used these drills using an external pace.

The clinical outcomes of treatment of tendinopathy vary—there is currently no single effective treatment.  Studies have shown that there are neuromuscular adaptations associated with the persistent pain of tendinopathy and compensatory strategies to move outside of painful ranges of motion or loads at those ranges.   These motor control changes do not return to normal once the pain of tendinopathy has resolved.  Tendon neuroplastic training proposes a concept of externally paced exercise to decrease cortical inhibition and increase cortical drive to the muscle.

Here is an interesting article on the subject: Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review.

Stay tuned, there is a full video article on externally paced exercise for tendinopathy coming soon to the blog!

Even though impingement is normal, and while there is no way of preventing all forms of injuries, there are many ways in which we can make the body more robust and resilient.  Because of the complexity of the shoulder complex, shoulder pain is quite common in the training world, especially where overhead work is involved.  Knowing this, it is a good idea to include prehab or maintenance work in your shoulder workout.

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Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U

 

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