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Resistance training is a popular form of exercise for weekend warriors and elite athletes alike. Unfortunately for some, this passion can lead to many injury complaints. Research has found that 36% of injuries in the weight lifting population occur at the shoulder complex1. Some of the most common movements at the gym eliciting shoulder pain include the chest press, chest flies, shoulder press, lat pull down, push-ups and power clean. This pain can start off as a nagging pain during lifting but can progress into a constant shoulder pain and even pain at night. It is important to recognize and address shoulder pain with lifting early on to avoid more serious injuries and prolonged time away from the gym.
The cause of shoulder pain in lifters is often multi-factorial. Potential causes include training errors (rapid increase in training load, frequency, duration), poor technique, previous injury, participation in overhead athletics and collision sports, poor rest, nutrition etc..
The pathology of shoulder pain with lifting also varies greatly. Sub-acute injuries include rotator cuff tendinopathies, long head bicep tendinopathy, glenohumeral joint instability, and distal clavicle osteolysis. Acute injuries include biceps and pectoralis tendon ruptures and shoulder dislocations. We will dive into each one of these pathologies and how it affects our ability to perform lifts.
The role of the tendon is to transfer force generated from muscle to bone. All tendons require a healthy load/capacity relationship whereas the tendon capacity exceeds the muscle load. If the tendon capacity is reduced (deconditioning/atrophy) or the load demand increases (higher volume or intensity of load) the tendon begins to fail which leads to a cascade of negative events referred to as a tendinopathy. You can think of a tendinopathy as a swollen, grumpy tendon that is irritable to load
Tendinopathies can develop chronically or acutely. Acute development of tendinopathy (reactive tendinopathy) occurs when there is a sudden change in training type or increase in training load or frequency. This sudden change does not allow the tendon to build a load tolerance to the new stimulus resulting in the onset of tendinopathy symptoms. An example of this would be a lifter that has taken 2 months off from shoulder press and tries to jump back into his previous training weight with no buildup. Chronic tendinopathy often develops as a result of being exposed to repetitive loads with poor strength maintenance or inadequate rest to recover. An example of this would be a lifter that trains shoulder press 4-5 times per week incorporating poor rest between lift sessions and neglects strengthening of the smaller shoulder stabilizer muscles i.e. rotator cuff muscles.
The lifter with tendinopathy symptoms often presents with well localized shoulder pain that is initially load dependent but can progress into a constant aching pain and pain at night. There may also be a sharp pain with overhead mobility, which is referred to as shoulder impingement.
Now to understand rotator cuff injuries in relation to lifting you need a good understanding of the role of the rotator cuff (RC). The RC consists of four muscles. These muscles work together to stabilize the head of the humerus in the shoulder joint (glenohumeral joint- GHJ). The RC muscles are placed under significant stress to stabilize the GHJ during upper extremity weight lifting2.
Weight lifters often put an emphasis on targeting the larger muscle groups of the upper extremity (deltoids, pecs, trapezius), but often neglect the RC muscles. This can create an imbalance of strength between the global muscles and local stabilizing muscles of the shoulder. This miss match, in combination with repetitive loading, biased exercise selection, and training errors precipitate RC tendinopathy.
Our main goal is to always keep our athletes in their sport/activity during rehab whenever possible. However, depending on the intensity, irritability and duration of symptoms, a short period of time off from weight lifting may be necessary to offload the tendons. This offloading phase is closely followed by a gradual graded tendon loading program and eventual return to weight lifting. Upon return to weight training there are important modifications to consider to reduce the risk of re-injury.
We will use the bench press for example. Modifying the hand spacing and grip when returning to bench press from RC injury are instrumental in reducing the risk of re-injury. Hand spacing should be no wider than 1.5x the biacromial width (AC joint to AC joint). The narrower hand space reduces the peak shoulder torque and therefore reduces the RC and biceps tendon stabilization requirements of humeral head stabilization3,4. The narrower hand space also allows for a shoulder abduction angle less than 45 degrees and extension less than 15 degrees. These modified angles put the pec major and biceps brachii at a mechanical advantage resulting in less stress on the RC and distal clavicle3.
In addition to hand spacing, grip type is also an important consideration in the return to lifting. The underhand grip (supination) rotates one of the RC tendons, supraspinatus (SSp), out from under the acromion, reducing the risk of impingement during the pressing motion. Whereas the overhand (pronated) grip draws the long head bicep tendon out from under the acromion but places the SSp under the acromion5.
As you can see from the literature, simple consideration of hand spacing and grip type can be instrumental in the successful return to lifting of an athlete dealing with rotator cuff tendinopathy/shoulder impingement.
Weight lifters often put an emphasis on targeting the larger muscle groups of the upper extremity (deltoids, pecs, trapezius), but often neglect the RC muscles. This can create an imbalance of strength between the global muscles and local stabilizing muscles of the shoulder. This miss match, in combination with repetitive loading, biased exercise selection, and training errors precipitate RC tendinopathy.
Our main goal is to always keep our athletes in their sport/activity during rehab whenever possible. However, depending on the intensity, irritability and duration of symptoms, a short period of time off from weight lifting may be necessary to offload the tendons. This offloading phase is closely followed by a gradual graded tendon loading program and eventual return to weight lifting. Upon return to weight training there are important modifications to consider to reduce the risk of re-injury.
We will use the bench press for example. Modifying the hand spacing and grip when returning to bench press from RC injury are instrumental in reducing the risk of re-injury. Hand spacing should be no wider than 1.5x the biacromial width (AC joint to AC joint). The narrower hand space reduces the peak shoulder torque and therefore reduces the RC and biceps tendon stabilization requirements of humeral head stabilization3,4. The narrower hand space also allows for a shoulder abduction angle less than 45 degrees and extension less than 15 degrees. These modified angles put the pec major and biceps brachii at a mechanical advantage resulting in less stress on the RC and distal clavicle3.
In addition to hand spacing, grip type is also an important consideration in the return to lifting. The underhand grip (supination) rotates one of the RC tendons, supraspinatus (SSp), out from under the acromion, reducing the risk of impingement during the pressing motion. Whereas the overhand (pronated) grip draws the long head bicep tendon out from under the acromion but places the SSp under the acromion5.
As you can see from the literature, simple consideration of hand spacing and grip type can be instrumental in the successful return to lifting of an athlete dealing with rotator cuff tendinopathy/shoulder impingement.
An athlete may develop anterior shoulder instability as a result of previous shoulder dislocations/subluxations or a gradual insidious onset. In the athlete with previous shoulder dislocation it should be noted that a conservative management plan may not always be successful. The presence of a bony lesion to the humeral head called a Hill-sachs lesion or Bankart lesion to the glenohumeral labrum may result in chronic instability of the shoulder joint that will result in discomfort and disability under high loads. Surgery may be indicated for this individual if their goal is to continue to lift heavy weights.
The lifter with anterior shoulder instability will present with poorly localized pain in the ‘high five’ position under load and commonly has an athletic history of overhead sports (volleyball, tennis, baseball, swimming) or previous shoulder dislocation/subluxations.
The ‘high five’ position refers to the position of the shoulder when high fiving another individual. In this position the shoulder is placed in 90 degrees of shoulder abduction and 90 degrees of shoulder external rotation. This is considered a high-risk position for individuals with anterior shoulder instability as it puts stress on the main passive primary stabilizer of the shoulder, the inferior glenohumeral ligament (IGHL)6.
Weight lifting frequently puts the lifter in this high five position under load. This includes exercises such as the wide grip bench press, incline and supine flys, wide grip pull down, and behind the neck shoulder press. In addition, weight training is often repeated until muscular fatigue is achieved. This means that as the dynamic stabilizers (RC muscles) of the shoulder become fatigued additional stress is placed on the IGHL and anterior shoulder capsule6.
Treatment of the lifter with anterior shoulder instability often consists of rest from loading the high five position in order to settle potential inflammation in the shoulder. In addition, the lifter should be thoroughly examined to determine RC and scapular stabilizing strength prior to return to lifting.
Upon return to lifting, modifications should be put in place to limit loading the high-risk position. We will use the behind the neck lat pull down for example. This variation of lat pull down puts an increased strain on the IGHL/anterior capsule by placing the shoulder in the high five position. A simple modification to this exercise would be to have the athlete seated with the torso declined in 30 degrees of trunk extension. This modification removes the high five position and creates better recruitment of the periscapular muscles providing increased humeral head stabilization. EMG studies also show that this position puts the lats at a mechanical advantage meaning the lifter is not sacrificing his target muscles with this modification7. Considerations of hand spacing is also important for similar reasons mentioned earlier.
Distal clavicle osteolysis is often referred to as ‘weight lifters shoulder’ due to the prevalence of the condition in weight lifters. Osteolysis refers to the process of excessive bone degeneration, where the cycle of bone uptake (osteoclastic activity) is out competing the process of new bone formation (osteoblastic activity).
The lifter with distal clavicle osteolysis often presents with pain and tenderness well localized to the distal clavicle aka AC joint. This pain is initially present during lifting but can progress to into a constant pain.
An athletic history of sport involving repetitive trauma to the AC joint (hockey, lacrosse, football) may predispose the athlete to distal osteolysis. These athletes may need to limit or modify exercises such as the power clean to avoid further repetitive micro trauma to the clavicle.
Modifications to the power clean to minimize risk of injury to the clavicle include performing a “power pull” only, where the lifter does not rack the bar. The second option is to use bumper plates so that the lifter can drop the weight during the deceleration phase as opposed to racking.
Treatment of distal osteolysis includes rest, NSAIDs and addressing training and/or biomechanical errors.
The majority of reported pectoralis major tendon ruptures are the result of bench pressing (47-70%)8. Clinically the lifter will report pain at the time of injury and present with bruising, weakness and pain with abduction of the arm, and have a palpable defect in the anterior axilla (arm pit).
Complete tears at the musculotendinous junction (where the muscle and tendon meet) account for 20% of tears and are commonly managed non-operatively. Avulsion injuries (lifting of where the tendon attaches onto the bone) are managed operatively8.
The anatomy of the biceps brachii muscle is that it has two proximal tendon heads that insert onto the scapula. The short head attaches onto the coracoid process whereas the long head biceps (LHB) originates into the glenoid and posterior superior labrum. The distal insertion of the biceps brachii is a common tendon insertion onto the radial tuberosity below the elbow joint. 90% of bicep tendon ruptures occur proximally at the long head biceps8. Distal bicep tendon rupture is much less common and often involves an avulsion off the radial tubercle.
In the lifting population the bicep tendon is most at risk for acute rupture during eccentric (lengthening) contraction with a weight of 68kg or more8. This type of bicep contraction occurs during bicep curls and rowing movements.
Clinically, the lifter will report a “pop” or “snap” at the time of injury, have weakness with elbow flexion and forearm supination and have an observable “pop eye” sign which signifies a recoil of the muscle belly.
Management of bicep tendon rupture differs based on location of the tear, age and physical demands of the patient and concern of cosmetic deformity. Long head bicep tears are often managed non-operatively as elbow flexion and forearm supination can still be achieved through the short head biceps. A patient that opts for operative management of LHB tear is usually a younger athlete or manual labour worker that has high physical demands of the biceps or is unsatisfied with having an ongoing “pop eye” sign deformity in the biceps. Distal bicep tears are now almost always managed operatively since a study in 1985 by Morrey et al9 reported a 40% supination strength loss and 30% flexion strength loss in non-operative group compared to the operative group at 1 year post surgery. Non-operative management of distal biceps rupture is reserved for sedentary or elderly populations with low physical demands.
Summary
In summary the prevalence of injuries to the shoulder complex in weight lifters is high. Shoulder pain in lifters is often a result of a history of previous injury, participation in overhead or collision sports, training errors, strength imbalances, and/or poor sleep and nutrition. It is essential that the weight lifter be evaluated early in the presentation of lifting pain to avoid extended time off from the gym. It is our goal as physiotherapists to manage and resolve the injury via a thorough history and physical examination and applying vital lifting modifications.
Blake joined GRSM in July 2018. Blake graduated with his B.A. Hons – Major: Kinesiology from the University of Western Ontario and a Master of Physiotherapy from the University of Sydney. Blake’s graduating class at University of Sydney ranked 1st in the 2017 QS World University rankings for sports-related subjects including Physical Therapy, Sports Therapy and Rehabilitation.
Blake has worked in hospital & multi-disciplinary clinics and has also been the team Physiotherapist for the University of Sydney Women’s Australian Rules Football Team. Blake has always been an avid sportsman growing up playing hockey, soccer, baseball, and volleyball. His dedication for sport has developed into a passion for treating sport-related injuries and promoting a healthy active lifestyle.
Blake’s treatment style focuses on the implementation of exercise and manual techniques to relieve pain and improve function. He also believes that a comprehensive injury education is important in enabling his clients to take control of their injury and optimize their outcomes. In his free time Blake enjoys staying active playing recreational baseball and hockey as well as taking his dog Louie for hikes.
References:
Saragiotto, B. T., Maher, C. G., Hancock, M. J., & Koes, B. E. (2017). Subgrouping Patients With Nonspecific Low back Pain: Hope of Hype? Journal of Orthopaedics & Sports Physical Therapy, 47(2), 44–48.
O’Sullivan, P., Caniero, J. P., O’Keeffe, M., & O’Sullivan, K. (2016). Unravelling the Complexity of Low Back Pain. Journal of Orthopaedics & Sports Physical Therapy, 46(11), 932–937.
The Robin McKenzie Institute Canada. (2017). Part A: The lumbar Spine.
The Robin McKenzie Institute Canada. (2017). Part C: Advanced Lumbar Spine and Extremities Lower Limb.
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This patient came in with a painful and disturbing clunking sensation while reaching overhead. With his consistency you can see his progress through his injury rehabilitation.
