Shoulder impingement is an incredibly common injury amongst athletes, with up to 43% of athletes experiencing some form of the pathology during their career. However, its not just competitive athletes who have the potential to suffer from shoulder issues, as shoulder impingement is incredibly common amongst regular strength training enthusiasts, with many often diagnosing themselves with the dreaded ‘impingement syndrome’ that often prevents them from performing exercises such as the bentch press and military press, two incredibly important strength and size builders. It is vital that lifters possess the knowledge of what’s causing their pain, how to fix it, and how to prevent it from reoccurring to ensure steady progress is made in the gym.

Shoulder impingement sufferers often describe the pain as a burning or pinching experienced around the Glenohumeral Joint. To be more specific, the technical term for this type of impingement is called Subacromial Impingement, and occurs when the subacromial space (Area between the humeral head and the acromion process) is narrowed, causing an encroachment or ‘pinching’ of surrounding tissues. There are other types of impingement, such as internal impingement, which commonly occurs in baseball athletes. However this is pretty exclusive to throwing sports, and is a topic for another article! Subacromial impingement can often cause excruciating pain when raising the arm above its resting position, particularly under heavy load such as in the bench press. In fact, performing such exercises without consideration of strengthening other vital musculature that aids in shoulder health can actually cause more shoulder pain.

subacromial-space

DISCLAIMER: I’m not saying that exercises like the bench press are inherently bad and indefinitely cause shoulder pain. The bench press is a fantastic size and strength developer. What I am saying is that without proper consideration of muscular balance surrounding the Glenohumeral joint and the scapula, the bench press can contribute to the narrowing of the subacromial space, which will be explained in detail later in the article. This is where many gym bro’s and dogmatic lifters go wrong. They perform an exercise, begin to experience pain, and immediately write the exercise off as ‘bad’ or ‘dangerous’. In many instances the exercise is only made dangerous by either bad technique, or by neglecting proper muscular balance, postural integrity and efficient movement.

Efficient scapula movement on the thorax aligns the ball (humeral head) in the socket (glenoid fossa) creating joint congruency and healthy movement of the scapula as the arm moves overhead. In order for healthy, efficient scapula movement, a number of movements need to occur: Upward rotation and posterior tilt of the scapula, and external rotation of the humerus. Alterations to these efficient movements massively contribute to shoulder impingement by narrowing the subacromial space, therefore it is incredibly important that lifters strengthen muscles that are responsible for eliciting these movements, and inhibit (Lengthen) muscles that prevent these movements from occurring.

Why we should STOP Rowing so damn much

You will often hear coaches/athletes/regular gym bro’s regurgitate the traditional ‘wisdom’ on dealing with shoulder issues. Most often we hear the claim that you must perform an equal ratio of pulling and pushing exercises to ensure muscular balance of the anterior and posterior upper body is maintained, and if you’re experiencing any shoulder pain, its because you’re not performing enough rowing movements. There are a number of flaws with this theory. Although a strong back is vitally important to all athletes, excessive amounts of rowing often feed into the problem further without an adequate understanding of anatomy. The issue lies with the musculature that is predominantly targeted with pulling movements, namely the lats and upper traps. Now, the lats are an internal rotator of the humerus and also aid in extending the spine (Due to their attachment at the thoracolumbar fascia) therefore if they become tight and overactive, will pull the arm into a constant state of internal rotation, and excessive thoracic extension, losing an athletes natural kyphosis in the thoracic spine. As previously mentioned, we need external rotation of the humerus for healthy scapula movement, NOT internal rotation. Also, when we lose the natural kyphosis of the thoracic spine, this further inhibits the scapula’s ability to move on the thorax efficiently. Furthermore, The upper trapezius muscles role is clavicular elevation, which can cause excessive anterior tilt of the scapula if it becomes tight and overactive. As aforementioned, we need posterior tilt of the scapula for healthy scapula movement, and excessive anterior tilt only serves to narrow the subacromial space of the shoulder. As we can see, rowing is not necessarily the answer to shoulder impingement issues, and in many cases, if we perform more pulling movements to try and counteract shoulder impingement symptoms it will actually make the issue worse.

Other muscles we need to prevent from becoming overactive include pec major (as it internally rotates the humerus) and pec minor (as it performs downward rotation of the scapula) – two movements we want to avoid getting stuck in if we want to maintain a healthy scapula-humeral rhythm. As I alluded to earlier, this is why the bench press can often feed into impingement issues, because it can leave an athlete with an incredibly tight pec major/minor, narrowing the subacromial space. The Solution? Lengthening of the muscles that have a tendency to become tight and can hinder healthy glenohumeral movement, and activating muscles that promote optimal glenohumeral movement.

The Beauty of Reaching – And why stretching isn’t always the answer

Reaching whilst moving the upper limbs above or in front of the body restores the natural kyphosis (rounding) of our thoracic spine, allowing the scapula to move smoothly and congruently on the thorax. This is something that is lost in many athletes and gym goers, who are often stuck in an extended posture where the lats and paraspinals are pulling the spine into extension, and as a result, the anterior core is chronically lengthened. In this position, the diaphragm is forced to function as a postural muscle instead of a muscle of respiration, as the ribcage is flared. This causes other muscles (such as the lats, upper traps, paraspinals and pec minor) to play a major role in assisting respiration. This means that we are never really able to inhibit the muscles that drove us into faulty posture as we are constantly using these muscles too much during respiration. In this instance, stretching these tight muscles will never really help the issue because as long as we are using these muscles to breathe, they will always tighten up again. Thus, we must first teach our body new motor control strategies by putting ourselves in positions where these muscles are inhibited, and then allowing the diaphragm to properly engage in respiration in these new positions to elicit long-term neuromuscular change and make real postural changes.

When we look at the bench press, what position are we adopting? That’s right, an extended posture, with the scapulae retracted and the thoracic/lumbar spine stuck in extension. The opposite of what we want for optimal scapula movement. Again, this isn’t to say that the bench press is innately bad, however a lifter has to ensure that there is adequate attention placed on contracting musculature and performing movements that will prevent the athlete from permanently adopting an extended posture, where the natural kyphosis of the thoracic spine is lost, the anterior core is lengthened, and the diaphragm cannot be used for respiration. In order to offset dysfunction caused by the bench press, we need to promote thoracic flexion through protraction of the scapula, we need a posterior pelvic tilt to prevent us from maintaining an over extension in the lumbar spine, and we need good anterior core activation in order to draw the ribcage down and thus use the diaphragm for respiration.

90/90 Breathing

First and foremost we must learn how to draw the ribs down, engage the anterior core and use the diaphragm for respiration. The 90/90 position is a fantastic way of teaching proper breathing mechanics and ribcage control. Assume this position against the wall with a 90 degree angle at the hip and knee. Begin with a full exhale to bring the ribs down whilst simultaneously lifting the hips off the ground slightly (posterior pelvic tilt) to engage the hamstrings. From this position, reach through the ceiling and inhale through the nose, expanding the diaphragm and ribcage 360 degrees. Then exhale fully again, until there is no air left in the body, whilst maintaining this position. Repeat for 2-3 sets of 4-5 breathes. The addition of the roller between the legs is to provide some adductor activation to help further facilitate the posterior tilt of the pelvis.

All Fours Breathing

Now that we have set the optimal breathing pattern, we must establish some thoracic flexion and posterior pelvic tilt in order to inhibit muscles that pull us into an extended posture and prevent the scapula from moving effectively. All fours breathing is a brilliant way to achieve this. In a quadruped position (all fours) exhale fully to bring the ribcage down. Then, posteriorly tilt the pelvis (Tuck the belt buckle up) and reach through the shoulders and upper back, creating some thoracic flexion. You should feel a contraction in the abs, obliques and glutes. Then inhale, trying to fill the upper back with as much air as possible. Then exhale fully until there is no more air in the body. Repeat for 2-3 sets of 4-5 breathes. This is particularly good between bench press sets as the movements directly oppose the movement utilised when benching.

Muscles we need to activate

Now that we have a good knowledge of the causes of shoulder impingement, and have performed breathing based movements that inhibit the onset of this extended posture, what are the muscles that need to be strengthened? We already know that in order for efficient scapula-humeral rhythm we need upward rotation and protraction of the scapula. Two of the main muscles responsible for this movement are Serratus Anterior and Lower trapezius, with lower trapezius also possessing the ability to posteriorly tilt the scapula, another important function of healthy arm elevation. Serratus wall slides are a brilliant exercise for isolating the serratus anterior muscle, and Y’s can be a great way of targeting lower trapezius.

Serratus Anterior Wall Slide 

Placing the hands on the roller, start off with a full exhale in order to draw the ribs down and squeeze the glutes to prevent the pelvis from anteriorly tilting. From here, reach through the shoulders to round the upper back, and then slowly push the roller upwards, focusing on the movement of the scapula on the thorax. Resist the urge to shrug the shoulders (as this would place dominance on upper trapezius) and ensure that the shoulders remain externally rotated by keeping the elbows tucked to prevent muscles such as subscapularis from becoming dominant. This combination of scapula protraction and upward rotation makes this a brilliant warm up drill before any pressing movement.

Lower Trapezius Goblet Half Y 

Traditional lower trapezius Y’s are a great way of improving scapular stability, and the addition of the unilateral loading with the kettle bell and the squat position helps to lock your lumbar spine into a fixed position, preventing overextension. Clean the kettle bell to the shoulders, exhale fully to draw the ribs down, and then sink into a squat. From this position, reach your arm overhead to engage lower trap, ensuring all the movement comes from scapula rotation. A brilliant drill to perform before pressing movements or olympic lifts.

The rotator cuff musculature also plays an incredibly important role in shoulder health. The rotator cuff is a collection of 4 muscles that help to stabilise the GH joint and prevent excess superior translation of the humeral head that occurs through deltoid activation. If the strong pull of the deltoid forces the humeral head into superior translation, the subacromial space will be inevitably narrowed, increasing the risk of impingement. Because the rotator cuff muscles’ role is to provide dynamic stability, it is often suggested that they must be trained in a dynamic fashion, where reflexive stability of the rotator cuff is crucial in order to maintain position. The bottoms up position is excellent for developing reflexive stability of the rotator cuff, and the half kneeling position is great for forcing anterior core stability and glute activation which will help to prevent an over extended lumbar spine – something that we want to avoid as previously mentioned.

Half Kneeling Bottoms up KB press 

The half kneeling kettle bell press is a brilliant exercise for promoting shoulder and core stability, and is best performed as part of a warm up before pressing movements/Olympic lifts, or when rehabbing a shoulder injury.

The bottoms up position provides a challenge to reflexive shoulder stability as the rotator cuff muscles must contract dynamically to keep the humerus centred in the GH joint, and the half kneeling position promotes anterior core and glute activation. Begin with a full exhale to draw the rib cage down and create a neutral spine, whilst squeezing the glute on the back leg to prevent anterior tilt of the pelvis. With control, press the kettle bell overhead, ensuring the core remains braced and the lower back remains neutral. Reach through the shoulder to ensure activation of scapula musculature, then slowly lower the kettle bell.

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