Shoulder pain and lifting
Shoulder pain is one of the foremost reasons for people taking time off lifting, and thus lack of observable gains. Most shoulder pain is:
- Easily observable;
- Technique error dependant;
- Can be reduced and even combated by yourself;
- Easily diagnosable by a healthcare professional;
- Occasionally very dangerous and even life threatening.
Anatomy of the shoulder
The shoulder is in fact a collection of joints in the upper limb. The shoulder is comprised of the glenohumeral joint (ball and socket), the acromioclavicular joint (commonly sprained) and the scapulothoracic joint (not a true articulation, comprised of the connection between the shoulder blade and the body), and the sternoclavicular joint (attachment of the clavicle to the ribcage). See image for anatomical locations of the joints. All of these joints have to work together in order to have a healthy functioning shoulder, so there is a lot of room for error, and thus pain.
The scapulothoracic joint is a connection between the scapula (shoulder blade) and ribcage. If you watch someone lift their hand over there head, you will see their scapula rotate as their hand lifts, this is called the scapulothoracic rhythm and for every 10 degrees the glenohumeral joint moves, the scapulothoracic joint should move 5 degrees (2:1 GH-ST ratio). The scapulothoracic joint is not a true joint, it is in fact a muscular connection in which the scapula is sealed down by a series of muscular slings comprised of: serratus anterior, romboids, pec minor, lat dorsi, trapezious upper mid and lower. So if any of these muscles switch off (become inhibited), this can cause the scapula to assume a dysfunctional pattern of movement, leading to excess stress on the glenohumeral joint with ensuing rotator cuff issues.
The glenohumeral joint is what we all think of when we first think of “the shoulder”. It is comprised of the humerus (upper arm bone) and the scapula (shoulder blade), it is a ball and socket joint, and quite a shallow one at that. The shallowness of the joint allows for a greater range of motion, however this comes at a cost – instability. The glenohumeral joint is innately unstable and relies on the passive support of the joint capsule and the active dynamic support of the rotator cuff. The rotator cuff is comprised off: supraspinatus, infraspinatus, teres (maj/min) and subscapularis.
The AC joint is the articulation between the clavicle and the scapula. It works in synergy with the SC (sternoclavicular joint) to anchor the scapula onto the ribcage.
Do you have a rotator cuff tendonitis?
This is not to negate a healthcare practitioner examination, case history and diagnosis, this is instead to give the general public a point of reference before seeking professional help.
Here I have listed a few steps you can take to see if you have a supraspinatus/biceps tendonitis. Positive tests here do not substitute for a proper examination, nor can you accurately diagnose a problem across the internet.
Now, I will try to introduce what people mean by muscle inhibition. When you contract your biceps, your triceps automatically relax. This is a concept we call “reciprocal inhibition” and put simply means that if the biceps are “on” the triceps are “off” as these two muscles work in tandem, they are what we call agonists/antagonists. Taking this concept further, if the tone in the biceps is consistently increased, we can infer the tone in the triceps is consistently “dulled down” or inhibited. This is very important for the nervous system, as we ideally want to keep muscles relatively balanced in order to reduce the change of injury.
These agonists/antagonists are all over the body. Some useful ones are: glute max/hip flexors, pecs/rombs-lower trap, deep cervical flexors/upper traps-suboccipitals. If one side of the scapula is constantly shortened (tone increased) then the other side of the scapula will be constantly lengthened (tone decreased) pulling the scapula out of position. When we allow these relationships to destructively propagate over time, we end up with predictable clinical signs that we term upper/lower crossed syndromes. I will now give some common signs of the upper crossed syndrome in relation to shoulder pain.
Rounding of the shoulders – this leads to a reduced space for the tendon of the supraspinatus.
Forward head carriage – this accompanies the rounding of the upper back, forward head carriage is associated with headaches and weakened stabilisers in the neck.
Muscles inhibited: romboids and lower traps.
Muscles overactive: pecs/min and maj, subocciptials.
Pain is often felt over the front of the shoulder, when severe pain may spread down the upper arm. This is what we call referral.
- In this picture the therapist has his thumb on top of the supraspinatus tendon which, if inflamed, would be painful.
- Here the therapist has his thumb on the other common location of tendonitis – the long head of biceps.
Pain can be very severe and is often described as a “toothache” in the shoulders, it is often deep and dull at rest with sharp stabbing felt on aggravating movements. Pain may begin only on certain movements, however over time will most likely progress to a general low-level pain that will not leave and is often aggravated by attempting to sleep on your side.
Painful arc: pain below 90 degree abduction.
Using your painful arm to touch the top of the shoulder on your non-painful arm.
Reaching upwards, putting on a coat, brushing hair, opening doors all become very difficult.
Treatments need to be focused first: reducing inflammation can be done at home with regular application of an ice pack, three times per day for 15 minutes at a time. Appropriate anti-inflammatory medicines may also be prescribed by your GP or pharmacist (over the counter medications such as ibuprofen can be of use). If you choose to seek the help of a therapist, they will be able to speed up the reduction of inflammation with modalities such as ultrasound.
Restore balance: first, tight structures need to be released (pecs, subocciptals) also joints need to be realigned, normally with manipulation. Once all tight structures have been released, your therapist will then begin to strengthen/activate inhibited muscles. It must be done in this order, never strengthen an inhibited muscle without releasing the tight agonist first.
A great therapist will never treat just the sight of pain, often the dysfunction in the shoulder will have originated from issues elsewhere in the body. A full body examination is warranted to find all possible sources of compensation – if you only receive treatment on the site of pain, your therapist is often missing half the picture.
Example of successful therapy
So, for example, joe bloggs approaches a therapist, he has a rotator cuff tendonitis which he has had for months. We find that the external rotators have switched off (become inhibited), so what do we do? Prescribe 3 x 10 external rotations with a theraband, forever or until the pain fades and he stops being bothered.
So what has been accomplished here? All we can hoped to have accomplished is increase the body’s ability to perform an external rotation with a theraband, this follows the SAID principal (specific adaptations to imposed demands). We have not changed the speed of contraction, the global stabilization, the mobility in the thoracic spine or the stabilization in the transverse abdominis.
We have in effect done nothing to prevent his problem from reccurring; he may as well have taken ibuprofen and waited.
"The biggest predictor of injury is previous injury."
Someone is messing up here? We have chiropractors, osteopaths, strength and conditioning coaches, physiotherapists and rehabilitation specialists. We have a new buzz word every couple of years, core strength, functional fitness, dynamic stability. Nothing is working, people are still getting injured over and over again. Patients once out of pain are discharged and sent back to the gym, only to represent weeks/months later. So what are we missing?
Pain is the last thing to appear and the first thing to disappear, dysfunction is deviation from the ideal ROM/a lack of stability and far more pertinent to gym goers. Mike Boyle and Gray Cook have created a joint-by-joint approach to mobility and stability that clears up many issues for us as gym goers.
Lumbar spine – stable
Thoracic spine – mobile
Scapulae – stabile
Glenohumeral – mobile
Elbow – stable
Wrist – mobile
Makes sense right? So let's apply this to joe bloggs and his rotator cuff – the client's thoracic spine is stiff, which throws off the stability in the scapula allowing his shoulders to round which locks up his glenohumeral joint, finally ramming his supraspinatus tendon into his acromioclavicular arch. Now when we apply those theraband external rotations, we can see they are doing pretty much nothing at all to solve the patient’s problems on a larger scale. Until the thoracic spine starts to move the scapulae will always try to compensate for it by moving in excessive and unnecessary ways, never giving the glenohumeral joint a chance to do its job.
Steps of successful rotator cuff rehabilitation:
Control inflammation, release tight muscles, correct hip movement, low back stability (core), thoracic mobility drills, scapulothoracic stability, then finally move onto rotator cuff rehab – strengthen (resistance training) coordination/proprioceptive training – finally integrate into movement patterns.
So there you have it, if you think you're suffering from a rotator cuff issue, please think about who you’re going to trust with your shoulder!
Dr Luke Thomas Neal