I am regularly contacted by fellow martial artists, trainers, and fitness enthusiasts about shoulder pain. Chronic shoulder pain, the kind that keeps people up at night, wanting to saw their shoulder off for relief. The person is often on a regular diet of NSAIDs, and has been to a chiropractor or physiotherapist without any joy. They’ve done program after program of shoulder rehab.
Where is the breakdown? What are we getting wrong? And why the hell haven’t I written about it, so I can send the next person who asks an article, rather than a long-ass Facebook message or email?
When it comes to diagnosing the cause of pain in a sophisticated joint like the shoulder, it’s complicated. If you have painful shoulders, it’s worth going to see a professional. But what I’ll bring you today are some out-of-the-box strategies that I’ve used to get myself and others out of chronic shoulder pain.
Just Stop It
It all starts with removing the negatives. As I mentioned in my knee pain article, people often just need to stop doing what is hurting them. When your health professional says to rest, do it. But there may be more to consider than just what you do in the gym. Renowned physical therapist Dr. Shirley Sahrmann tells us:
“The real reason behind a painful pattern is daily, everyday activities. It’s actually not the way you stretch before a workout. It’s not the way you let your elbows flare in the bench press or how you do your crunches. None of those things are good choices, but they may not be as harmful as simpler, non-training tasks.”
Many people think only about adding things to their programming to fix shoulder pain, or to avoid it. I am a big fan of corrective shoulder programs, but truth be told, a lot of them aren’t working for people. We need an approach that helps us stop doing the things that are creating pain in the first place, rather than a whole heap of stuff to prehab, rehab, or treat it after it already happened. No amount of rehab or prehab can possibly undo the damage you are doing to your body daily if you are not mindful and willing to stop doing the things that hurt it.
Postural Strain and Movement Quality
Scientists and practitioners love to argue about whether there is such a thing as poor posture, or one correct posture. It’s true that there is limited evidence to suggest that shoulder injuries are caused by poor posture, mainly because there are way too many variables to consider in studies. But I strongly believe that many people are doing considerable damage to their bodies every day just by how they sit, stand, sleep, and do daily activities.
Regardless of whether you define it as postural strain (a term I prefer over “poor posture”) or not, there are millions of people in non-industrialized countries who sit and stand for extended periods of time, and do hard manual labor, and have no neck, back, or shoulder pain. It is how they sit, stand, sleep, and work that is the game changer. The way they position their body keeps them out of pain.
Some of the biggest breakthroughs I have seen have happened after I helped people to stand, sit, sleep, and do mundane daily tasks (i.e., move) better. I have alleviated shoulder pain (and back pain) with some clients by having them avoid
- One-sided dominance: driving, using their computer mouse, brushing their teeth, using their phone with the same hand all the time
- Sleeping on their painful side, or sleeping on their stomach with their arm overhead
- Carrying a heavy bag over one shoulder
- Sitting rotated in one direction in an office environment
- Sitting in bed cross-legged, hunched over a computer for hours
- Vacuuming, lifting furniture, and twisting in a flexed position
- Sitting on their wallet in the back pocket
If you are in pain, take a long look at what your day-to-day movement habits are like. This is where the damage is done. Esther Gokhale’s book “8 Steps to a Pain-Free Back” is a great reference for position and posture.
Your Program or Technique Need Work
Check your exercise selection, order, load, volume, and technique. My article Advanced Programming Principles For Shoulder And Knee Health covered this very thing for balancing the scapula and improving shoulder health, and the quads and hamstrings for knee health.
If you have shoulder problems and train regularly, I can say with little hesitation that there is probably something amiss in your programming that is putting your shoulder into pain. For instance, if you spend a lot of time in flexion and do a lot of overhead work and pressing in general, this is a recipe for disaster. Check your technique and specifically look at the position of your setup for your exercises. Eliminate those exercises that take you into pain or are painful after training.
Mix It Up
If you cannot stop doing what is causing you pain, for example if it’s your work, your only other option is to try and vary what you are doing. Move from a seated to a standing workstation from time to time. Try some walking meetings.
If you have to hold pads as a trainer and that is hurting you, try some foam sticks instead. If BJJ is hurting your shoulder, try to avoid always being hunched up in your guard on one shoulder defending a guard pass, and instead try working your takedowns, your top-position game, and your guard-passing game. If you train as an orthodox fighter, train as a southpaw for a while. Try some cross training. Try a different sport or hobby.
Most joint problems are from overuse, repetitive movements and patterns, and over-specialization. Most people need to move more, but moving differently, with more variety can be a real key to improving your pain. Once you have removed the negatives,” it’s time to look at adding something new or changing some things up.
Get In Line
What comes first in corrective exercise: mobility, stability, or strength? Trick question! The answer is alignment. We often damage our joints from the way they are loaded or stressed, and alignment can be a big player in how these stresses are distributed through the joint.
Neck problems can be shoulder pain in disguise. The thoracic area or rib cage being twisted or out of whack can play havoc for the shoulders. Even the pelvis plays a role. It is all connected. Some people abhor the idea of manipulations or adjustments, but sometimes they are necessary. You can torque, pull, and stretch on a particular area, but if the joint needs to be manipulated and put back into place, you might not be able to get it done on your own.
Should You Even Be Doing That?
Movement screens and baselines can be amazing tools for judging whether any movement, stretch, or exercise is good for you. Otherwise, how do you know something is actually good for you?
Lots of people tell me that yoga, or Pilates, or their shoulder rehab program is working for them, without being able to explain why, or even show me what’s improved. When pressed, they’ll regurgitate the dogma that they’ve read or been told. Then the very same individuals will complain in the next breath about how much pain they are in, or that their symptoms are worsening.
If what you are doing shuts down your body for days, it’s hard to argue that it’s working. Think objectively about whether what you are doing is working for you, or whether you just think that it is.
Use a baseline test, like a shoulder s-pattern, arm raise against the wall, active straight leg raise, toe touch, neck turn, etc. Try any corrective exercise, and then retest against your movement baseline. Simply put, if your body likes it, your ROM or symmetry will be the same or preferably better. If it doesn’t, then it will be worse. This is a highly beneficial strategy, but one I seldom see used or taught.
With a little bit of body awareness, you can determine whether things are good for you. You can both see and feel whether your movement is better as a result of what you are doing.
Not Everything Works for Everybody
If I had a dollar for everyone I know who has gone to a physio for a shoulder problem, with their only take-home being to rest and do some resistance band external rotations, I’d probably be a millionaire. This one-size-fits-all approach hasn’t worked for most people I know, and it doesn’t address the underlying cause of why the rotator cuff isn’t doing its job (hint: it’s not the rotator cuff).
I’ve seen online fitness “experts” push the band pull-apart as the be-all and end-all for shoulders, and movement culturists such as Ido Portal pushing passive hanging as the cure for shoulder problems. But I have found that my own shoulders, as well as those of some of my clients and peers, are actually worse after passive hanging.
The point is that not all things are for all people, so be careful of cookie-cutter programs or cure-alls for shoulders. They don’t always work. Check it with a movement baseline as described above, and pay attention to how your shoulders feel the next day or two to find if it’s the right thing for you.
Get After It
Often, people will say “I did something to my shoulder in the gym today.” Here is the truth: It’s unlikely you hurt your shoulder that day. That session was just the straw that broke the camel’s back. Tissue damage and dysfunction take time. You’ve been hurting your shoulder for some time, with your posture, your movement habits and your training.
And it will take time to change all that. You need to be aggressive (within limits) to change how your body works. When I ask people how their rehabilitation is going, I often get a negative answer. They’ll admit that they aren’t doing the exercises at all, or not enough to affect a positive outcome. People can complain about their physiotherapy not working, but in my experience, it is often nothing to do with the physiotherapist, but with patient adherence to the program.
The Functional Movement Screen (FMS) uses the following flow:
Applying that framework to shoulder care might look something like this:
- Diaphragmatic breathing progressions from prone or supine to various positions
- Soft tissue work: Foam rolling of t-spine, rhomboids, lats, and some gentle extension over roller. Massage ball of pec minor, 1st rib, erector spinae
- Mobility and flexibility: Cat/cow, wall dog, chest to floor stretches, rib pulls, Bretzel variations, thoracic windmill, FMS t-drill, lateral flexion and side bending, side-to-side lat stretch from child pose, side reaching from various positions, pec and lat stretching, posterior capsule stretches, seated and standing shoulder extension stretches
- Motor control: Wall slides, reach, roll and lifts, kettlebell arm bar, T’s, Y’s and W’s, band pull-aparts, 3-way band pull aparts, side lying dumbbell external rotations, standing band external rotations, dumbbell t-raise
- Strength: Deadlift variations (yes, they connect the shoulder to the torso), rowing variations, reverse flys, loaded carries, crawling, and creeping
The missing ingredients in a lot of shoulder programs are motor control (i.e., stability) and strength work. Motor control cements and integrates gains in mobility into movement patterns, and strength locks them in. The order in which things are done matters, and so does doing all the steps of the protocol outlined in the FMS.
Get It in Your Warm Up and Cool Down
Resetting the body before or after a workout will help reverse the damage done from the work day or training itself, and is a great way to prevent issues before they come up. Try doing the opposite of what you did in your workout or at work. If you did a big overhead press session, try some hangs or loaded carries to decompress the spine or the shoulders by putting them into traction. Just finished a BJJ session, spent on your back defending the guard pass in flexion on one side? Then try some gentle extension and lateral flexion to open up that side. Just finished a super-heavy, high-threshold deadlift or back squat session? Try 7-10 minutes of shaking, vibration, and oscillation of the body to change the tonus, relax the nervous system, and loosen up.
If you suffer from shoulder pain, try these protocols. They can change your life and help solve your pain for good. If you follow this and get an outcome, please drop me a line and let me know how you got on. Remember, pain and injuries don’t have to be a curse, they are just feedback, and an opportunity to learn. If you are training hard at anything, injuries are almost guaranteed to happen. But if you are smart, you can limit your time away from the thing you love.