Most people do not like going to a physician unless it is absolutely necessary. Athletes, especially, really dread going to the physician and hearing those deathly words “surgery,” “rest,” “physical therapy,” and “avoid your sport.” Hopefully, a few of these questions I am providing may help to ease the stress, strain, and anxiety of discussing a shoulder injury for the first time and help you get back to your active life.

Rotator Cuff Strain

One of the most common injuries is going to be the rotator cuff strain, which if left untreated, can turn into a complete tear. Just look at professional baseball players and the number who have had surgery.

Once a physician has said rotator cuff, begin to think of questions that affect that particular activity. For example, “What is the recommended treatment?” From there, questions that can be asked include “What type of physical therapy will be needed?” and “How long will I be in therapy?”

The scary part for many is approaching the subject of imaging and further diagnostic testing. My suggestion is, if the physician doesn’t recommend it right away ask why. Ask “How long do I try therapy before we do more testing?” Sometimes, physicians are hesitant to begin with imaging and try to take a more conservative approach. If you are that concerned, you can push the issue or ask for another opinion. Personally, I think pushing the issue may be the best initial approach.

Dislocation/Subluxation of the Shoulder

Another injury that happens quite frequently is the dislocation or subluxation of the shoulder. Here is where it gets tricky. A shoulder dislocation can cause damage to so many structures within the shoulder that the treatment is widely variable. Structures that can be injured range from the musculature to the ligaments to the labrum. All of these structures incorporate similar yet different physical therapy components.

This is when it is important to ask the appropriate questions. First and foremost, ask about immobilization. How long will the shoulder need to be immobilized before physical therapy can begin? What are the short-term effects of being immobilized? What activities can I do while in the sling? Will there be additional imagining, such as an MRI? What are my limitations at work and/or in regards to activity? The fear people have is hearing the worst – that you can’t do anything. In most cases, physicians are willing to work with you on certain limitations, especially when it comes to work.

Remember, a dislocation will take some time to recover. Be patient, but be proactive at the same time. If you don’t understand what is being said, ask the physician to slow down and explain in terms that you understand. The worst feeling is leaving the office and not knowing what was said.

Shoulder Surgery

A dislocation or subluxation can lead to a worse scenario – surgery. That is most likely the worst word any person wants to hear. Believe me, I know. I have had four knee surgeries, one hand surgery, and one ankle surgery. Yes, the orthopedist likes to see me walk into the office.

When there is the chance the topic of surgery will be approached, go prepared with questions. Most importantly, find out what type of procedure will be used. Ask the physician to explain it. Then, find out what the risks are that are involved with surgery. What is the success rate of the procedure? A key question for people today is, “How much work am I going to have to miss?” The younger athlete may ask, “How long I am going to be out of my sport? Will this affect my chances of a scholarship?” These are all valid questions to consider when deciding on the course of action.

It even comes down to whether or not you want to do surgery with that physician. You have the right to a second opinion. Get it. If surgery is something that may affect your career, ask for a second opinion. You never know, maybe the other physician has a better procedure or has other options. It never hurts to check it out, especially when it can affect your livelihood.

Listen Carefully

The last bit of advice I can give is to listen carefully to what the physician is saying. Why? As the physician explains the injury, surgical procedure, or physical therapy, you may come up with additional questions that I didn’t include. If the questions are open-ended and require more than a yes/no answer, you should be able to go through a whole series of questions that will help you to ultimately get the answer for which you are looking.

Always ask, even if you think it is not important, if you are thinking about it then it is important to you. It’s your shoulder. It’s your health.

You might also like How To Self-Diagnose Your Shoulder Pain and this list of articles how to prevent and treat shoulder injuries.

The post The Best Method for Talking to Your Doctor About Shoulder Injury appeared first on Breaking Muscle.

I will share several specific exercises with you – all of which I recommend as an orthopedic surgeon and physician. I suggest you do the exercises three times per week, for three sets, each of which should include ten or fifteen repetitions.

Also, please note that heavy weight does not have to be used, as it is vital you control the weight while performing these exercises.

Understanding the Muscles of the Rotator Cuff

The rotator cuff is comprised of four muscles:

1. Infraspinatus
2. Supraspinatus
3. Subscapularis
4. Teres minor

All of these muscles give stability to the shoulder and each has a specific, unique attachment to the upper humerus, or arm. Each muscle works in conjunction with the others to provide the harmony of motion essential for maintaining the muscular stability of the shoulders and preventing injuries such as rotator cuff tendonitis or rotator cuff tears. These muscles work in union with the labrum to keep the shoulder in the best positions kinematically when exercising or participating in sports.

“These muscles around the shoulder are extremely important for stabilizing the shoulder joint, which can ultimately assist in preventing shoulder injuries.”

The anatomy of the rotator cuff muscles is worth reviewing and understanding. These four muscles have specific attachments, origins and innervations. Knowing their origins and attachments gives us better insight into how these muscles perform.

Supraspinatus Muscle

The supraspinatus muscle originates on the supraspinatus fossa of the scapula. This particular muscle inserts on the highest portion of the facet of the greater tubercle of the humerus. The supracapular nerve innervates this muscle. This muscle essentially allows for lateral rotation of the humerus and initiates the abduction of the arm.

RELATED: The Best Method for Talking to Your Doctor About Shoulder Injury

Infraspinatus Muscle

This muscle originates on the infraspinatus fossa of the posterior aspect of the scapula. The muscle inserts on the middle aspect of the greater tubercle of the humerus and is innervated by the suprascapular nerve. This muscle serves to laterally rotate the humerus.

Subscapularis Muscle

The subscapularis muscle originates on the subscapular fossa of the scapula and inserts on the lesser tubercle of the scapula. This particular muscle is innervated by the upper and lower subscapular nerves and serves to medially rotate the humerus.

RELATED: A Quick Look at Preventing and Treating Shoulder Instability 

Teres Minor Muscle

Lastly, the teres minor muscle originates on the upper aspect of the lateral border of the scapula and inserts on the lower part of the greater tubercle of the humerus. The teres minor muscle is innervated by the axillary nerve and serves to adduct and rotate the humerus laterally.

Exercises to Prevent Common Shoulder Injuries

Understanding the basic function of the rotator cuff muscles can give you insights about how we activate and use them. This will also afford you an opportunity to learn and practice exercises that can prevent strain and/or tear of the rotator cuff muscles.

“These injuries can be devastating to a person’s well being and athletic performance, and can even make general day-to-day activities quite difficult.”

Common injuries associated with the shoulder that I evaluate in my orthopedic practice include the following:

• Rotator Cuff Tendonitis
• Rotator Cuff Bursitis
• Rotator Cuff Tears
• Labral Tears
• Shoulder Contusion
• Glenohumeral Ligament Strains and Tears

Rotator cuff injuries can affect individuals across a multitude of lifestyles and fitness levels. These injuries can be devastating to a person’s well being and athletic performance, and can even make general day-to-day activities quite difficult.

These injuries can be caused by over-exercising, lack of exercise, improper form, heavy and improperly controlled weights, or accidents in the gym while using weights. I also evaluate shoulder injuries in patients who attempt to use heavy weights for overhead military presses and in patients who attempt to do complex exercises they see in intense exercise and fitness DVDs.

Here are the exercises I highly recommend as a physician and as an athlete that will assist you in strengthening your rotator cuff and potentially preventing injury:

1. Internal and External Rotation Dumbbell Curls.
2. Abduction Shoulder Dumbbell curls.
3. Forward Flexion Shoulder Raises/Forward Raises.
4. Pendulum Exercises: Circle & Reverse Circles.
5. Pendulum Exercises: Crosses.

All of these exercises are demonstrated in the video below, so use this as a visual reference to ensure proper form and technique. Do not use heavy weight for these types of exercises.

Again, I recommend three sets of each exercise for ten to fifteen repetitions, three times a week.The goal of these preventive shoulder exercises is to assist you in avoiding shoulder injuries and to elevate the level of your athletic performance and safety prowess. So remember to go at your own pace, so that all exercises can be executed with quality form. This is essential to the health of your shoulder.

Learning more about your shoulders:

Understanding the Shoulder and Bulletproofing it from Injury 

The post Avoid Shoulder Injury by Strengthening the Rotator Cuff appeared first on Breaking Muscle.

The shoulder is complex, but as a strength athlete, the demands placed on it aren’t. Your shoulder only needs to do a few things well to stay healthy and happy for the length of your lifting career. Here I’ll specify what your shoulder needs to do and how to fix it if it can’t.

Basic Shoulder Anatomy

The shoulder complex is generally described as containing four joints: 

• The glenohumeral (GH) joint – where your upper arm meets your shoulder blade
• The scapulothoracic joint – where the shoulder blade moves on your ribcage
• The acromioclavicular joint – where your shoulder blade meets your collarbone
• The sternoclavicular joint – where your collarbone meets your sternum

Within this complex are a host of muscles that enable the shoulder to move. The rotator cuff crosses the GH joint and is made of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. The scapular muscles of upward rotation (upper and lower trapezius and serratus anterior) and downward rotation (rhomboids, middle trapezius, levator scapulae, and pectoralis minor) are located in your upper back with the position of your pectoralis minor, which is proximally attached on the third, fourth, and fifth ribs. On top of that are the primary shoulder complex muscles like the lats, pectoralis major, and deltoids.

Rotator Cuff Real Talk

The purpose of the rotator cuff is one of the most poorly understood concepts in popular fitness. This is probably to do with the etiology of rotator cuff injuries. Rotator cuff problems are common in throwing athletes and other individuals whose sports have heavy overhead demands. As a result, we have a lot of evidence about cuff injuries and experience with their rehab.

The name “rotator cuff” is also a bit misleading. The cuff absolutely rotates the humerus on the glenoid, but its real purpose is to maintain joint centration. Basically, it keeps the humerus stuck into the glenoid fossa in the most optimal position for stability and force development. There are two parts to this task:

1. Proper strength in the required direction. Seeing as the goal is to keep the humerus stuck into the joint, the cuff needs to be good at resisting distraction.
2. Proprioception. Proprioception is the ability of little nervous organs in your tendons to keep your brain informed of your joint positions. It’s hard to maintain optimal alignment when your nervous system is working with faulty data.

Many people exhibit passive internal rotation of their shoulders, but this is not usually a rotator cuff issue. Both the latissimus dorsi and the pectoralis major can internally rotate the humerus, and in addition to poor scapular position, these two tend to be the primary culprits of passive internal rotation. Instead of focusing on stretching your tight lats and pecs, work on obtaining a neutral position of the thoracic spine and scapulae to clear up your passive internal rotation issues.

Exercises for Rotator Cuff Health

Deadlifts and loaded carries are good exercises to improve the traction strength of your cuff. However, it’s important to use a weight that won’t actually pull your shoulder down so you can maintain perfect form and ideal scapular position.

Kettlebell screwdrivers and arm circles are two of your best options for improving rotator cuff proprioception. Adding these two exercises into your warm up should be enough to wake up your nervous system.

Kettlebell Screwdriver:

• Lie on your back with your knees bent and your feet resting flat on the floor. This is called a hook lying position.
• Place a light kettlebell in one hand.
• While keeping your shoulder blade neutral, raise your arm straight up into the air (basically the bottom position of a Turkish get up).
• Rotate your arm clockwise and counterclockwise. Maintain your scapular position, and make sure your upper arm is rotating, not just your forearm.
• Do this 10-15 times per side.

Arm Circles:

• Stand with good posture and raise your arms in front of you 90 degrees.
• Thinking of your middle fingers as a pen, draw small circles and slowly expand them until they’re roughly the size of a dinner plate.
• Change directions and repeat.
• Do this 3-4x in each direction. Keep your arms dead straight the entire time and focus on feeling the motion at the shoulder.

Deadlifts can be great for improving rotator cuff traction strength, provided the load isn’t so heavy it pulls your shoulder out of position.

Scapulae – The Foundation of Shoulder Stability

Unfortunately, not everyone who has cuff injuries has cuff issues. Sometimes the rotator cuff tendinopathy is a symptom of something else, like poor scapular positioning, or scapular dyskinesis. In my experience, this is far more often the primary cause in strength athletes.

The scapulothoracic joint is unique in that it doesn’t have a true articulation like most joints. Your scapulae move on the surface provided by your thoracic vertebrae and your ribs. While the specifics of scapular motion are complicated, the most important aspects are proper resting position, and healthy upward and downward scapular rotation.

Neutral Resting Position

The go-to movements for creating a neutral resting position are diaphragmatic breathing, followed by scapular squeezes with external rotation. The breathing will help you achieve a more neutral thoracic spine and the retraction will help return your hopelessly abducted scapulae to a more neutral position, about three inches from the center of your vertebrae.

Diaphragmatic Breathing:

• Assume a hook lying position as described earlier.
• Rest one hand on your stomach and the other on your sternum.
• Take deep breaths, drawing the breath down and into your belly.
• Exhale forcefully and feel your core muscles contract to help push the air out.
• Continue for 2-3 minutes, or until you feel some of the tension in your upper back start to dissipate.

You are trying to breathe into your stomach first and then let the air inflate your lungs from the bottom up. You should feel your stomach rise for the first ⅔ of the breath and your chest rise for the last ⅓. Your upper back should press into the ground lightly when your lungs are fully inflated.

Scap Squeezes With External Rotation:

• Assume a standing position and take a deep breath.
• As you exhale, roll your shoulders back and feel them relax downwards. This is your starting position.
• Bend your elbows 90 degrees, so your palms face each other.
• Tighten the muscles in your mid back and pull the scapulae together. Your hands should start to move outwards.
• Once you’ve squeezed your shoulder blades as far as you can, move your hands backward while maintaining the 90 degree bend at the elbow. You should feel additional tension in the upper back.
• Now relax to the starting position.
• Repeat this sequence (starting with the scapular squeeze) for 2-3 sets of 10-15 reps, or until you can feel your scapulae in a better position.

Upward Rotation

If you have trouble getting your arms overhead, try wall slides with forward pressure.

• Place the pinky side of your hand on a wall like you’re trying to karate chop it.
• Apply a bit of pressure forwards like you’re trying to push the wall over.
• While maintaining pressure, slide your hand upward in a slight outward diagonal.
• Reach as far overhead as possible without shrugging.

The forward pressure should help wake up your serratus anterior to increase upward rotation and give you some more range. Once that gets easy, start to take your hands off the wall at the top like you’re doing the Y in YMCA, but make sure you don’t extend your back or raise your ribs. This should help strengthen your lower trap.

Once you can perform wall slides with perfect form, my favorite exercise for improving upward rotation is the overhead press. Craig Marker recently wrote a great piece on how the bottoms-up kettlebell press in particular can improve shoulder stability through nervous irradiation.

Downward Rotation

Most people don’t have as much trouble with downward rotation, but strengthening the muscles in your mid back is important for overall shoulder health. These muscles include the middle trapezius, rhomboids, levator scapulae, and pectoralis minor.

To target this area, try rowing exercises with a slow, controlled motion. Focus on retraction at the end of each rep. A few sets a week on a cable machine or bodyweight rows are all you need.

Slow, controlled rowing exercises can help with scapular retraction and downward shoulder rotation.

Putting It All Together

Here is an example of how these exercises can be incorporated into a simple warm up before a shoulder-heavy workout:

• Diaphragmatic breathing: 2-3min
• Arm circles: 15 reps each direction
• KB screwdriver: 15 reps each side
• Banded retraction with external rotation: 10-15 reps
• Y-wall slide with liftoff: 15 reps
• Overhead press: 10-15 reps with an empty bar, or bottoms up press with light kettlebell

Repeat for 2-3 rounds.

Throw in some pulls or loaded carries and there you go: A simple routine to keep your shoulders healthy and happy without spending hours on maintenance. 

Complex Joints, Simple Maintenance

The human body is an incredibly complex machine and the shoulder joint is one of the best examples of this concept. The movement potential of the joint is immense and allows us to do all sorts of awesome things from snatches to throwing 90mph fastballs.

Our bodies want to move well. To accomplish this, you typically don’t need complicated neurological reprogramming or twenty minutes of banded distractions to keep your shoulders healthy. All you need is to understand what the shoulder is supposed to do and practice those things in a safe way that reinforces proper alignment and motion. Keep things simple and your shoulders will thank you.

More on Joint Maintenance and Injury Prevention:

• 5 Injury Prevention Exercises to Build Bulletproof Athletes
• You Are Not Your Shoulder Ultrasound
• Banish Pain Permanently: Basic Drills to Repair Your Posture
• New on Breaking Muscle Today

Teaser photo courtesy of J Perez Imagery.

Photo 1 courtesy of Wikimedia Commons.

Photo 2 courtesy of CrossFit Impulse.

Photo 3 courtesy of CrossFit Stars.

The post Simplifying Shoulder Health for Strength Athletes appeared first on Breaking Muscle.

Nearly every athlete or lifter who’s trained for more than a couple years inevitably tweaks a shoulder. Sometimes, if you’re lucky, it hurts for a few days and then it’s gone. If you’re not so lucky, that twinge sticks around for years and you may even carry the hefty label of “shoulder impingement.”

This article will provide you with a few ideas for training around an injured shoulder and potentially even eliminating that twinge over time (depending on the source).

Let’s Talk Anatomy

First, let’s identify the major anatomical players we’re going to discuss:

• Scapula – the shoulder blade
• Humerus – the upper arm bone
• Acromion – the bit that sticks up from the shoulder blade and comes toward the front of the shoulder

The scapula, humerus, and acromion are the major anatomical players we’ll discuss today.

Most often, “shoulder impingement” is the diagnosis for shoulder pain. Shoulder impingement typically comes in two flavors:

1. External – pain manifests anteriorly (front of the shoulder)
2. Internal – pain manifests posteriorly (back of the shoulder)

The most common type of pain is in the front of the shoulder so the methods and exercises discussed here will be geared for those with external impingement/anterior shoulder pain. But before you proceed, you also need to be aware of whether your pain comes from primary or secondary impingement.

Primary vs. Secondary Impingement

Ever notice how some people can bench press until the cows come home and yet never seem to have shoulder pain? If I did that, my shoulders would be screaming within a month. Primary impingement is a result of structure or anatomy. For example the angle of the acromion will determine the size of the sub acromial space (the gap beneath the red bit below).

Depending on the angle, if your sub acromial space is smaller, it’s much more likely you’ll wind up pinching one of the many tendons that run through it. This little difference means some people can bench press forever without pain and some of us will have a perpetually tweaked shoulder no matter what they do. There will be certain movements that will always cause problems purely based on your anatomy.

“Primary impingement is a result of structure or anatomy. For example the angle of the acromion will determine the size of the sub acromial space.”

Secondary impingement is related to things like lack of mobility, scapular position, muscle tightness or stiffness, etc. and can be reversed if you improve these aspects through dedicated strength and mobility work. The substitutions listed below are great ways to continue training while you work on your mobility and let your shoulder heal. Increasing the amount of pulling versus pushing in your training can play a role, too, and there’ll be more on that later.

A Word of Caution

How to diagnose your shoulder pain – as primary or secondary – is outside the scope of this article. Unfortunately, the only way to truly know your anatomy is via x-ray or MRI. That said, it’s a safe bet that if you inevitably tweak your shoulder every time you overhead press, it’s best to stay away from that entirely.

Most people with shoulder pain probably already know what they can and can’t do. Be aware that the exercise substitutions below are general ideas and you should add or eliminate according to how your shoulder feels. You should also talk to a health practitioner if you’ve been experiencing chronic pain.

A Little Attention to Form

Before we talk about avoiding and substituting exercises, let’s briefly touch on position and form. If you are unable to achieve the proper position for a lift, say the overhead press, it will be tough to prevent injuries when doing that movement. Check out your shoulder mobility first – and then actually work on it – before loading up the military press.

When it comes to movement form, horizontal pressing and rowing can irritate the front of the shoulder if your rows look like the first two reps in this video. Instead, strive to imitate the form of the last two reps.

What you saw in the first two reps is called anterior humeral glide. It’s when the humerus (upper arm bone) drifts forward in the socket (it looks like it’s popping out in the front) and, as a result, all kinds of friction happens within the joint. Too much friction and – boom! – you wind up with angry shoulders.

Pay attention to how you’re performing your rows and presses and it will go a long way toward maintaining healthy shoulders.

Exercises to Avoid

• Overhead pressing
• Lateral and front delt raises
• Upright rows
• Bench pressing
• Pull ups
• Dips
• Back Squats

If you’re sharp, you’ll notice a common theme among these particular exercises. They entail one or both of the following:

• Humeral flexion – arm going over your head, as in the overhead press
• Humeral abduction – arm going out to the side, as in lateral delt raises or upright rows

Movements like the overhead press or lateral raise can close off the shoulder joint, particularly that pesky sub acromial space, which leads to tendons getting squished. The pronated grip (palms down) of pull ups and bench press also close the shoulder joint more than exercises done with a neutral grip.

Dips are the worst offenders, though. They automatically force the upper arm (humerus) forward in the socket, so we find ourselves in that anterior humeral glide – perfect for rubbing and pinching tendons.

Back squatting may or may not bother you, depending on your shoulder and thoracic spine mobility. But if you’re lacking in either, the typical arm position required by back squatting can be compromising to already tender shoulders.

Exercise Substitutions and Modifications

• Landmine pressing
• Push up variations
• Dumbbell floor presses
• Neutral grip chin ups
• Front squats

Note: You should still avoid front squats if you have an AC joint issue.

Landmine pressing is fantastic for people with cranky shoulders. This movement provides a semi-overhead angle while not requiring full-range shoulder mobility.

If you miss pressing, you can also give supine landmine pressing a whirl.

Push ups are almost always an acceptable substitute for horizontal pressing. The advantage of push ups over barbell or dumbbell work is the shoulder blades are able to glide freely on the rib cage. When you bench or dumbbell press, the scapulae (shoulder blades) are pinned down against the bench. As you bench, your humerus is moving independently from your shoulder blade, which is more likely to result in impingement because the humerus jams up into the acromion. In contrast, push ups allow for a free-moving scapula that moves along with the humerus and thus reduces the likelihood of impingement.

“Doubling your row volume relative to pressing volume can sometimes relieve shoulder pain and prevent it in the future.”

If you think you’ll shrivel up and die without some sort of press, dumbbell floor presses are the way to go. The floor prevents the elbows from traveling past the body (and thus prevent anterior humeral glide) and you can use a neutral grip with dumbbells, which keeps the sub acromial space open. The same can be said about neutral grip chin ups. The more open grip allows for more wiggle room under that acromion.

Reconsider Ratios

Many workout programs incorporate a press-to-pull ratio of 1:1. When you have an injured shoulder, one training modification you can employ is to increase the ratio in favor of rowing, to more like 1:2 or 1:3 press-to-pull. Sometimes pain is simply an imbalance between front and back and increasing the rowing volume can solve your issue. For example, when pairing push ups with bent-over rows, you would perform twice as many sets of rows as you would push ups. You may find that after a few weeks your shoulder pain clears up.

The Take-Home

While this article is not even close to exhaustive, you should find a couple of tips that can help keep you and your shoulders happy.

• Remember to be mindful of the way you perform your presses and rows to avoid anterior humeral glide.
• Avoid exercises that require humeral flexion and abduction (arms overhead and arms out to the side) like the plague – at least for a few weeks while your increase the strength of your upper back muscles.
• Doubling your row volume relative to pressing volume can sometimes relieve shoulder pain and prevent it in the future.

As I’ve said before, you should walk out of the gym feeling like a superhero, not painfully grimacing as you drive home.

More Like This:

• Warm Up to Lift Big: A Movement Prep Blueprint for Strength
• 4 Drills to Own Your Position in the Big Lifts
• Super D’s Mobility Video Library
• What’s New On Breaking Muscle Today

Photo 1 courtesy of Shutterstock.

Photo 2 by By BodyParts3D is made by DBCLS, via Wikimedia Commons.

Photo 3 courtesy of Kelsey Reed.

The post Who Has a Cranky Shoulder? How to Train Around It appeared first on Breaking Muscle.

The Shoulder and Overhead Motion

Maybe you’ve heard someone say, “The shoulder isn’t really designed for overhead motion.” I’ve never been able to wrap my head around that idea. You’re telling me that the shoulder, the joint possessing the largest functional range of motion in the human body, simply wasn’t “designed” to use roughly 50% of that movement?

If that’s the case, then what exactly are these people talking about? Well, there happens to be an exceedingly strong correlation between individuals who spend a lot of time with their hands above their heads and shoulder injuries. However, any good scientist will tell you that correlation does not imply causation. If the link between overhead movement and shoulder injury is merely a correlation, then what’s the cause at the heart of it?

The Trapezius and Shoulder Impingement

The trapezius is a trapezoid-shaped muscle that sits in the center of your upper back. You can look at the trapezius as two triangle-shaped halves bisected by your vertebrae. There are three different sections of your trap, the upper, middle, and lower.

For our purposes we are going to focus on the upper trap, which originates from the occipital protuberance, the upper third of the superior nuchal line of the occipital bone and the ligamentum nuchae (a strip of connective tissue that runs down your cervical vertebrae) and inserts on your clavicle. Those are some fancy science words for saying the upper trap starts in the back of your head and attaches to your collarbone. Over-activation of the upper trap and under activation of the middle and lower trap is one of the most common issues that leads to shoulder pain and impingement.

It happens something like this: Initially, when we spend a lot of time with our arms overhead we start with good mechanics. Unfortunately, after a while certain muscles get tired. It’s hard for your middle and lower traps to stabilize your shoulder for hours on end. So what happens? Your upper trap has to pick up the slack. It begins to shorten in order to passively hold your shoulder in the position you keep putting it into. This requires less energy and in some ways is “easier” on your shoulder.

The problem is that once your upper trap becomes short it pulls your shoulder out of a good position. When your upper trap is tight and your shoulders are elevated it becomes increasingly difficult to fire the middle and lower traps, which means they are no longer capable of stabilizing your shoulder or assisting in scapular motion. This means that all of the demand gets re-routed to the upper trap and the vicious cycle continues.

Despite overhead motion often being the scapegoat, over-firing upper traps are painfully common even in desk workers. When you sit hunched over with your shoulders scrunched up and your head forward you are placing your traps in a shortened position. Add to that rounding of the upper back and now you’ve placed your mid and lower traps in a lengthened, disadvantageous position.

In addition to the problems you get at the shoulder (anterior pain, overhead weakness, and a predisposition to labral and rotator cuff tears), upper trap tightness can also cause debilitating headaches. It’s really not fun. I don’t recommend it. Now combine bad posture, tight traps, and overhead motion and you’ve got a recipe for disaster.

The Added Problem of the Serratus Anterior

The other missing link of shoulder stability is often the serratus anterior (SA), also known as the finger muscle (due to it’s appearance) or the boxer’s muscle (due to it’s pronounced definition in prizefighters.) Your serratus anterior originates on your ribs and inserts on the medial border of your scapulae, meaning the side closer to your spine.

Your serratus essentially sits underneath your shoulder blade and is yet another muscle responsible for scapular motion and stability. When it fires properly, the serratus protracts your shoulder, basically sucking the scapulae right up against your ribcage. When it’s not working your scapulae can pop off your back (known as winging) and are significantly less stable.

As you can probably guess, when the SA are weak, the stabilization demand on the already over-taxed upper trap is increased yet again. Additionally, if you already have upper trap tightness your traps are probably pulling your scapulae in a position that makes it harder for the SA to fire properly. Can you see how all these problems feed into one another?

What You Can Do About It

You have to learn to stabilize your shoulders properly. If I asked you to stabilize your shoulders, what would you do? I tend to find that this is a commonly overlooked aspect of training. Knowing how to brace your shoulders is every bit as important as knowing how to brace your core. You can’t have a stable structure on a weak foundation.

My article on posture has a simple explanation of the bracing sequence to reclaim your posture. Once you’ve done that, stabilizing your shoulders is just about squeezing the muscles of your mid back (mid and lower traps and rhomboids) and using them to maintain the position of your scapulae. Remember, core integrity is the first step. If you can’t properly brace your core, it’s almost impossible to brace your shoulders.

Of course it’s easy to say that, but what if you’re having trouble actually feeling it and getting your body to respond? There are hundreds of corrective exercises designed to improve shoulder stability, but I’m going to give you a few utilizing equipment you can find at your gym or box.

Stretching Your Upper Trap

With your head facing forward, place one hand on the opposite side of your head and pull your ear towards your shoulder. Make sure you are not rotating your neck as you do this. If you want to get really nasty and you have a friend you can trust, have your friend pin down a particularly tight part of your trap either with his or her fingers or a golf ball or lacrosse ball – then stretch. You can also tape a lacrosse ball to the underside of a barbell in a squat rack and use that to self-stretch the trap. Same basic principle applies: pin the tissue, then move your arms and neck to stretch the muscle.

Physio-Ball or Ring Stabilizations

You can perform physio-ball stabilizations with either two arms or one. All you’re doing is getting your shoulders into good position, bracing them, and then placing your hands on top of a physio-ball against a wall in a push up position.

You can progress from two arms to one arm on the wall, and when that becomes easy you can perform the exercise with two arms on the floor. Simply hold the position for as long as you can. Your set is over when your shoulders drop out of position, not when you can’t hold yourself up anymore. You have to be mindful of the difference or you could be simply reinforcing the issues that are already present. Build up to three sets of one minute.

If you want to get really nasty, gymnastics rings are fantastic for fostering shoulder stability. You can also easily adjust the angle and therefore the loading on your shoulder, all the way down to a full push up position. Again, work up to three sets of a minute, paying careful attention to the position of your shoulders.

The Strict Press

I think the best way to foster stable shoulders is the king of all shoulder exercises -the strict press. You might think I’m crazy, but think about it like a deadlift: yes, it can be terrible for your back when done incorrectly, but done properly the deadlift is arguably the most profound corrective exercise for posture. The strict press is the same for your shoulders. As long as you don’t have pain throughout the movement, starting light and paying strict attention to proper form will teach the shoulders how to stay stable in no time. Maybe you can even get those handstand pushups you’ve always wanted.

This concludes the second installment of my two-part series on how to deal with shoulder pain. Once again, mindfulness of your movements trumps all. The best solution for rounded shoulders and slouched posture is to not sit and walk around with rounded shoulders and a slouched posture.

Just remember, we should all be able to do basic maintenance on ourselves, but if you have persistent pain that is not changing at all and you have for weeks, you should seek proper medical attention. Make sure to take care of your shoulders and they will take care of you. Good luck.

Photos courtesy of Shutterstock.

The post The Dynamic Duo of Shoulder Impingement appeared first on Breaking Muscle.

The shoulder is a complicated joint. Where most other joints are basically a single bone fitting into another bone, the shoulder is a complex interplay between your humerus, clavicle, and scapula. Your shoulder joint is also in some way controlled or affected by almost every muscle in your upper torso. Your pecs major and minor, lats, deltoids, rhomboids, and upper and lower traps represent the primary movers. In addition you’ve got your rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis) and your serratus anterior that play pivotal roles in shoulder stability. The complexity of this joint is what gives it its incredible range of motion and allows it perform all the various activities it’s capable of, from throwing a baseball or a punch to split jerking three hundred pounds and doing single arm handstands. The shoulder is a profoundly intricate joint. Unfortunately, it can also be a little high maintenance.

The Relationship Between Posture and Shoulder Impingement

If you’ve read any of my articles then you know I’m a stickler for posture. Posture is the basis of proper movement and when your posture is messed up it short-circuits your athletic potential. It may not be the case with every individual, but my experience has been that most movement disorders originate not with the way we move during our one hour of exercise per day, but rather the way we hold our body the remaining twenty three.

Shoulder impingement is one of the most common postural issues, and anterior shoulder pain is often a sign of some degree of shoulder impingement. While this is a valid assumption, to me, impingement isn’t a valid diagnosis. It’s the musculoskeletal equivalent of “diagnosing” someone with a cough. There are treatments for a cough. There’s an entire aisle at your pharmacy full of cough remedies, and likewise, the most common treatment option for shoulder impingement remains something along the lines of, “Take an aspirin and rest.” But impingement, like a cough, is a symptom of a larger problem. There is certainly something to be said for managing symptoms, but the problem is never truly solved until it’s dealt with at its source.

How Shoulder Impingement Happens

Impingement occurs when the bony structures of your shoulder (particularly the acromion) begin to compress the bursa (a lubricating sac on top of the rotator cuff) and the underlying tendons. The differential diagnoses for impingement are myriad: rotator cuff issues, shoulder weakness, shoulder instability, bicep tendonitis/tendinosis, etc.

Frequently shoulder impingements will be treated as rotator cuff weakness, particularly in the external rotators. The logic goes something like this: If your arms are internally rotated, it must be because the internal rotators are shortened and the external rotators are lengthened and weak. Therefore, if you strengthen the external rotators the problem will resolve itself. Right? Well, no, not really. Impingement will absolutely cause rotator cuff weakness and frequently, when left untreated, will lead to rotator cuff and labral tears. Even so, none of this is evidence that the problem must be the rotator cuff.

What if you asked a friend of yours to perform a task for you, but before you even showed them the task you blindfolded them? Regardless of how capable or incompetent they may be, it’s unlikely they could successfully learn and execute the task while wearing a blindfold, although it’s possible they may figure out some sort-of similar, blind-man’s approximation. This is basically what’s going on with your rotator cuff. If your scapula is moving poorly or in a bad position, your cuff can’t fire correctly. It’s flying blind. Restoring proper function to your scapula can help remove the blindfold. You might still have some cuff strengthening to do, but correcting the scapulae should be step one.

Impaired Movements From Impingement

The two most common physical manifestations of impaired movement that I see are abducted scapulae and internally rotated humeri. That’s a fancy way of saying your scaps have shifted away from your spine and your shoulders are twisted down and forwards. Can you guess what position this is probably a result of? (Hint: it has to do with sitting.) Much like common dysfunctions at the hip, the problem is often anterior tightness secondary to over-activation of the anterior musculature coupled with posterior weakness from being lengthened all the time. Seems a good approach would be to mobilize the tight stuff and strengthen the weak stuff. Let’s start with mobility.

Step #1: Mobilize the Pecs

The first common area of anterior tightness is the pecs, both the pec major and minor. Now I know stretching has been kind of vilified in the fitness media as of late because it shuts off the muscle you’re stretching (which is bad for maximal force production), but what if you want the muscle to turn off, potentially in a situation where it’s been chronically over-firing? In this case, I think stretching is pretty fantastic.

My two favorite pec stretches are the door stretch and the foam roll pec stretch. To perform the door stretch stand in front of a doorway and raise your arms to just below shoulder height, palms forward. Now step into the doorway, allowing the doorjamb to press against your hands (or wrists, or whatever part of your lower arm is making contact) and push them backwards, eliciting a stretch along the pecs. This stretch can also be performed with your elbows bent at ninety degrees or one shoulder at a time for a more intense stretch. Hold for three sets of thirty to sixty seconds.

The foam roll pec stretch is a bit more passive and as such probably better at eliciting total relaxation. Lay down on top of a foam roller lengthwise with your head and pelvis supported on the foam roller. Now put your hands directly out in front of you like you’re doing the Hulk clap. From here, let your arms fall to your sides. Don’t let your shoulders ride up towards your ear, maintain a good position. You should feel a stretch in your pecs as your arms get lower. You can also place the foam roller on top of a table or bench so your hands can get below where the floor would be and increase the stretch further.

Another good option for mobilizing the pecs is a lacrosse ball. Stand facing a wall. Place the ball on top of your pec and lean into the wall, forcing your bodyweight onto the ball. Now you just have to kind of smash around in your pec until you find areas of tightness. You can either lean on them and consciously try to relax them away or, when you find a particularly bad spot, you can move your arm around while keeping your pec pinned with the ball to floss the tissues a bit. If you can find a corner to lean on so your arm can move freely past the wall, even better. Do this for two or three minutes per pec.

Step #2: Mobilize the Lats

The next mobilization target area is your lats. If you’re having trouble getting your arm into end-range flexion, then it makes sense to mobilize the muscle responsible for moving your shoulder the other way (extension), right? The tool of choice is going to be the foam roller.

A good lat stretch involves getting into the same position on top of the roller as you did for the pec stretch, but instead of letting your arms fall to the side, let them fall overhead. The key is contracting your abs and to keep your lower back flush with the roller. When we’re missing end-range shoulder flexion, frequently we’ll make up for it with lumbar extension, which is bad all around. By flexing your abs you lock your lumbar region in place and ensure the stretch is in the lats. Many people find that the weight of their arms is not enough to elicit a stretch, as the lat is a pretty big muscle. If this happens you can either hold onto a weight plate, a barbell, or a band, or have a friend apply gentle pressure to your arms until you feel the stretch. Again, try this for three sets of thirty to sixty seconds.

You can also smash your lats with a foam roller or lacrosse ball. Try to find areas of tightness and either relax them away with constant pressure or pin down the tissues and floss them by moving your arm. You’re trying to mobilize flexion, so moving into flexion would be the recommended method of flossing here.

Step #3: Strengthen the Weak Stuff

Hopefully you’ve restored some motion to those tied-up tissues around your shoulder. Now you’ve got to strengthen the opposing muscles to help maintain the new positions. The main target areas here are the rhomboids and lower traps, the muscles responsible for pulling your scapulae together and down.

Prone Ts and Ys are a great way to build initial strength. You can start with prone Ts and Ys on a table or bench and then progress to prone over a physioball. A row with lower trap emphasis can be performed by rowing from a high fixed point (head height or higher) and pulling down to your ribs with a strict focus on keeping the shoulders down and back. It may also be useful to perform these exercises unilaterally, as one scapula might be more jacked up than the other (weirdly enough it’s typically your dominant side.) Perform each exercise for three or four sets of eight to ten repetitions. Err on the side of too light rather than too heavy. It’s all about proper form here.

Just like with your hips, the best medicine for your ailments is often prevention. Learning how to achieve and maintain a healthy and stable position at your shoulders trumps all else. Sometimes we just need a little assistance in learning those basics.

Check back next time when I’ll be attacking the upper trap and serratus, two more of the usual suspects involved in shoulder impingement and instability.

Photo 1 by National Institute Of Arthritis And Musculoskeletal And Skin Diseases (NIAMS) [Public domain], via Wikimedia Commons.

Photo 2 courtesy of Shutterstock.

The post Why Does the Front of My Shoulder Hurt? appeared first on Breaking Muscle.

Many athletes deal with shoulder pain at one point or another. But how do you minimize the chances of this happening to you? And what is the best course of action if you do incur a shoulder injury? Read these ten articles to help you work it all out.

Understanding the Shoulder and Bulletproofing It From Injury (Tom Kelso)

Let’s take a close look at all the potential movements we can execute with the shoulder joint. Then, let’s look at how we can strengthen the joint and girdle to protect ourselves from injury.

The Thing You Do Everyday That’s Setting You Up For Shoulder Injuries (Brooke Thomas)

Many of us internally rotate our arms all day long while we work. Sadly, this exact positioning is a set up for a shoulder impingement or rotator cuff or labrum tear down the road.

A Quick Look at Preventing and Treating Shoulder Instability (Jeff Barnett)

Most athletes deal with shoulder pain at one point or another. The root cause for most of them is shoulder instability. But what causes instability and how can you fix it?

Why Do I Keep Jacking Up My Shoulder? A CrossFitter’s Dilemma (Meghan Hackler)

By correcting your mechanics and teaching your body how to move more efficiently, you’ll quit f’ing up your shoulder and start f’ing up WODs.

Do This, Not That: What People With Shoulder, Wrist, Knee, or Calf Issues Should and Shouldn’t Do (Andrew Read)

Reality is most of us are messed up in some way and there are just some things we shouldn’t do. But there’s always a way to work around a problem, avoid injury, and keep edging our way forward

I’ve Jacked Up My Shoulder: What Did I Damage and What Do I Do Now? (Meghan Hackler)

A decrease in scapular control places the glenohumeral joint at a mechanical disadvantage, and bigger muscles start to compensate for the smaller ones getting no love. Result? Shoulder pain.

The Best Method for Talking to Your Doctor About Shoulder Injury (Brandi Ross)

Communicating with doctors can be frustrating and overwhelming. Here are outlined questions you should ask your physician when you have a shoulder injury, to get the best quality treatment.

How to Heal Shoulder and Lumbar Spine Injuries (Lindsey Mathews)

As a health practitioner, the two most common injuries I see are shoulder and low back injuries. Here is my advice for how to handle and heal from these common athletic injuries.

The Facts on Rotator Cuff Injuries and Treatment (Doug Dupont)

Science takes a look at rotator cuff injuries and gives advice on how to treat them. While some rehab is recommended, conservative treatment is not the most effective option, according to researchers.

Mental and Physical Rehab for Injured Shoulders (Willow Ryan)

How often have we heard or said the words, “I have a shoulder issue.” Here are some tips for releasing your shoulder issues, including a yoga pose for healing and stretching.

The post 10 Methods to Prevent and Treat Shoulder Injuries appeared first on Breaking Muscle.

Sound familiar? This is a common theme among my athletes with chronic shoulder dysfunction. Physical therapy isn’t about fixing things. It’s about teaching people to move their stuff the way it was designed, efficiently, and with mechanical integrity. In a workout like the one above, shoulder and thoracic positioning are key. A five-round triplet like this, in theory, should take less than ten minutes with the correct weight, box jump height, and burpee scaling (yes, you can scale burpees). How often do our athletes scale appropriately? Ego is huge in CrossFit. Just ask me, I have one too.

The push press requires posterior shoulder mobility, thoracic mobility, and lat flexibility. When those things are not present, the shoulder joint is in a protracted (forward) position. Try this: slump forward, then raise your arm overhead. Doesn’t go far does it? Now sit up tall. Holy shit, you just increased your range by probably about forty degrees. By straightening up, you increased thoracic extension, put your scapula in the proper position on your thorax, and set your rotator cuff and scapular stabilizers for success, recruiting over twenty muscles to stabilize the shoulder joint and allowing you effectively lift that weight overhead. When those muscles are strong, you can do it over and over, with mechanical integrity.

The same holds true for the burpee. Burpees, more commonly used for punishment and responsible for rapid increases in heart rates, are often performed in the same crummy posture as overhead movements. Again, if you hit the deck with a collapsed thoracic spine, forward shoulders, and a crunched up neck, you’re going to have a bad time.

There are eighteen muscles alone that attach to the scapula. They have to work together at specific ranges of motion to control the scapula on the thoracic spine and subsequently place the shoulder joint in optimal mechanics. The muscles most often over-recruited in CrossFit are the pectoralis major and minor, upper trapezius, and deltoids. Left to their own devices, the lower trapezius, serratus anterior, and rhomboids forget their duty.

As the arm raises overhead, the scapula has to rotate upward one degree for every two degrees of humeral motion (different literature will yield a different measurement). If the scapular muscles aren’t getting the correct neurological input, they won’t fire at the right time, resulting in scapular dyskinesia. This decrease in scapular control places the glenohumeral joint at a mechanical disadvantage, and bigger muscles start to compensate for the smaller ones getting no love. Result? Shoulder pain.

Since the shoulder is rather complicated, the culprit of the problem may be difficult to pinpoint:

Biceps tendonitis:

This is usually associated with pain on the anterior shoulder, worst with overhead movement and tenderness to palpation. It can often be diagnosed with manual orthopedic tests and successfully addressed with rest, ice, and corrective strategies to decrease the impingement on the biceps tendon.

Rotator cuff tendonitis:

This may present similarly, although pain is usually on the lateral border of the shoulder and occasionally radiates into the lateral arm. Again, diagnosis is often confirmed with special tests, and a physician may order x-rays or MRI. Most research advocates physical therapy intervention prior to MRI or surgical procedure, which renders success. Occasionally, an injection may be needed or other more invasive management. Repeated injections are not encouraged, as the tissue quality of the rotator cuff isn’t all that great to begin with, and repeated injections of steroid certainly won’t make things improve significantly.

Labral pathology:

This pathology is generally characterized with repetitive clunking, catching, and popping in the shoulder joint. This may be worsened with overhead movements, kipping, and throwing. Labral issues seldom resolve to pre-injury status with physical therapy, as the tissue is damaged and often remains problematic. Instead of waiting for your labrum to tear, take the appropriate measures to learn to control your rotator cuff and scapular muscles.

If you have any of these symptoms, go find someone who knows what they are doing. You can look for a physical therapist at www.apta.org who specializes in orthopedic or sports physical therapy. You can also seek out a good orthopedist at www.aaos.org.

In short, if it hurts, and keeps hurting, get it checked out. If you have any of the symptoms described above, get it checked out. These symptoms could result in a much larger problem and more time away from doing what you love.

Photo 1 by LadyofHats Mariana Ruiz Villarreal (i did it myself) [Public domain], via Wikimedia Commons.

Photo 2 courtesy of Shutterstock.

The post I’ve Jacked Up My Shoulder: What Did I Damage and What Do I Do Now? appeared first on Breaking Muscle.

I often have someone in our gym come up to me at the end of a WOD asking advice about an ache, pain, or nag. In the last several months, it’s always been about the shoulder. “Hey Doc, I have this thing on the front of my shoulder that hurts with toes to bar.” “Hey Coach, should I do toes to bar?” “Hey Coach, why does my shoulder hurt with kipping pull ups?”

In the two years I’ve been coaching and CrossFitting, I’ve seen biceps tendonitis, rotator cuff tears, and labral tears. These injuries are not always mutually exclusive. The structures are housed closely together and dysfunction in one affects function in the other.

The biceps tendon courses through the subacromial space. This is an area made up of the head of the humerus (upper arm bone) and the acromial process of the scapula (shoulder blade).

There are four muscles that make up the rotator cuff: supraspinatus, infraspinatus, teres minor, and subscapularis. The supraspinatus courses through the subacromial space along with the biceps tendon and the subacromial bursa.

If the thoracic spine doesn’t have good mobility, the scapula then cannot be in correct mechanical position. Often, the scapula tilts forward, thereby closing down the subacromial space, creating impingement. This impingement causes the biceps tendon, supraspinatus tendon, and subacromial bursa to be inflamed. Add overhead motion to it, like push press or a kipping movement, and you’ve got yourself one pissed off shoulder joint.

The labrum is not forgotten in this dance of shoulder movement and mobility. It is the site of attachment of the long head of the biceps tendon. Often injured in overhead throwing athletes, the labrum’s purpose is to provide additional stability to the shoulder joint, with the assistance from the rotator cuff muscles. When the cuff is weak, the biceps tendon and labrum will take up the slack, attempting to provide additional stability. When the rotator cuff is already weak, and then gets fatigued with a kipping movement, the labrum takes over. Because of it’s low tensile strength, something has to give. If the rotator cuff doesn’t, the labrum will.

So, there are multiple reasons why you keep f’ing up your shoulder. The first steps toward rehabilitation are rest from the aggravating movement and re-evaluating your form. If you have a good CrossFit coach, talk to him or her about your form, and ask to be watched in a workout. Many of my athletes look technically sound during technique practice, but then it all goes to crap when the WOD is on and shit hits the fan.

Mobility exercises that you might find on mobilityWOD are the next step. K-Starr, also a physical therapist and CrossFit box owner, knows his stuff. When rest and mobility don’t work, it’s time to see someone smarter than you. In most states, you can see a physical therapist without a referral from a physician. A good physical therapist will listen to your method of injury, aggravating and alleviating factors, and perform an exam to determine what the exact pain-generator in the shoulder may be.

With a personal approach to corrective strategies, you’ll find the movements that used to hurt don’t anymore. In fact, they might even be easier. By correcting your mechanics and teaching your body how to move more efficiently, you’ll quit f’ing up your shoulder and start f’ing up WODs.

Shoulder joint diagram courtesy of NIAMS [Public domain], via Wikimedia Commons.

Photo 2 courtesy of Shutterstock.

The post Why Do I Keep Jacking Up My Shoulder? A CrossFitter’s Dilemma appeared first on Breaking Muscle.