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Progressive Exercise Strategies to Mitigate Shoulder Injuries Among Weight-Training Participants

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Nontraumatic shoulder disorders are prevalent among weight-training participants as a result of training patterns as well as adaptive shoulder joint and muscle characteristics. This article presents a progressive approach to exercises designed to mitigate well known joint and muscle characteristics that have been associated with shoulder disorders. Using a progressive evidence-based model, practical applications are presented that will guide sports medicine and strength training professionals in their ability to provide an evidence-informed upper extremity weight-training program for both patients and clients.
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Progressive Exercise
Strategies to Mitigate
Shoulder Injuries Among
Weight-Training
Participants
Guillermo Escalante, DSc, MBA, ATC, CSCS, CISSN,
1
Daniel Fine, SPT, CSCS,
2
Kyle Ashworth, SPT, CSCS,
2
and Morey J. Kolber, PT, PhD, CSCS
2
1
Department of Kinesiology, California State University San Bernardino, San Bernardino, California;
2
Department of
Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida
ABSTRACT
Nontraumatic shoulder disorders are
prevalent among weight-training par-
ticipants as a result of training patterns
as well as adaptive shoulder joint and
muscle characteristics. This article
presents a progressive approach to
exercises designed to mitigate well-
known joint and muscle characteristics
that have been associated with shoul-
der disorders. Using a progressive
evidence-based model, practical ap-
plications are presented that will guide
sports medicine and strength training
professionals in their ability to provide
an evidence-informed upper extremity
weight-training program for both pa-
tients and clients.
INTRODUCTION
The American College of Sports
Medicine guidelines recom-
mend that all adults should
implement resistance training to all
major muscle groups 2–3 days per
week (15); this is partly due to the over-
whelming evidence that resistance
training has positive effects on the mus-
culoskeletal system as well as in the
prevention of osteoporosis, sarcopenia,
lower back pain, and other disabilities
(48). Because of well-known health
and fitness benefits, weight-training
(WT) participation has gained signifi-
cant popularity over the last several
decades with an estimated 45 million
Americans engaging in resistance train-
ing regularly (6). Although the health
benefits associated with WT are well-
known, evidence suggests that there
are risks of injury associated with the
activity (16,25,26,35,41,42). Similar to
aerobic exercise, the risk of sustaining
an activity-related injury has been re-
ported to increase with higher duration
of physical activity per week (21).
To minimize the risk of injury, appro-
priate exercise technique, selection,
and progression may minimize
those risks.
Researchers have reported that up to
36% of injuries and disorders in the
WT population occur at the shoulder
complex (16,25,35,36). There are some
potential explanations for the relatively
high rate of injuries to the shoulder
region. The high degree of mobility
allowed by the shoulder joint comes
at an exchange of relatively decreased
stability. Researchers have hypothe-
sized that most WT programs empha-
size large muscle groups that produce
strength and hypertrophy, subse-
quently neglecting stabilizing muscles
of the shoulder such as the external
rotators (17). Furthermore, the shoul-
der, which is traditionally a non–
weight-bearing joint, has to assume
the role of a weight-bearing joint dur-
ing the course of repetitive lifting stress
placed on the shoulder with WT (28).
In addition, common resistance train-
ing exercises frequently place the
shoulder in injury-prone positions with
heavy loads such as end range of
motion external rotation with the
arm abducted (14). It should also be
noted that novice participants may also
predispose themselves to injury by pre-
maturely loading their shoulder(s) with
more advanced lifts without allowing
for necessary progression with appro-
priate technique.
Address correspondence to Guillermo Esca-
lante, gescalan@csusb.edu.
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REVIEW OF LITERATURE
Because of the high prevalence of in-
juries to the shoulder complex among
WT participants, researchers have
investigated shoulder joint and muscle
characteristics in healthy men and
women in the recreational WT popu-
lation (27,31) as well as in the WT
population with shoulder pathologies
such as subacromial impingement
(30,34), anterior glenohumeral instabil-
ity (32), and hyperlaxity (32). In one
study, shoulder joint and muscle char-
acteristics were investigated and com-
pared among WT participants and
controls (27). In the aforementioned
study, 90 men between the ages of
19–47 years were recruited, which
comprised 60 individuals who partici-
pated in upper extremity WT and 30
controls who did not perform WT. All
participants underwent an assessment
of active range of motion (AROM),
posterior shoulder tightness (PST),
bodyweight-adjusted strength values,
and agonist to antagonist strength
ratios. Briefly, the authors assessed
muscle groups and actions that func-
tion as force couples. Specifically, the
authors assessed muscle groups that
function together to achieve shoulder
movements. For example, the authors
assessed and compared the strength of
the shoulder abductors to the external
rotators as well as the upper to the
lower trapezius muscle groups and
then calculated the ratios. Higher ratios
implied greater imbalances. The re-
searchers reported that the WT partic-
ipants had decreased mobility when
compared with the control group for
all AROM measurements except exter-
nal rotation, which was greater.
Strength ratios were significantly
greater in the WT group when com-
pared with the control group (p,
0.001), implying agonist to antagonist
muscle imbalances. Specifically in men,
the strength of the larger muscle
groups was disproportionately stron-
ger than the smaller stabilizing muscu-
lature (e.g., rotator cuff and scapular
stabilizers). For example, the authors
reported an upper trapezius to lower
trapezius ratio of 8.04 in the WT group
compared with 5.65 in the control
group. Although it is expected that
the upper trapezius would have greater
strength than the lower trapezius, the
authors identified a greater imbalance
in the WT participants. These particu-
lar imbalances are of interest because
they have been associated with
Figure 1. Behind the neck lat pull-down exercise (high-five position-associated with
shoulder injury).
Table
Strength training exercises associated with shoulder injury
Exercises commonly associated with injury Shoulder injuries and disorders
1. Flat bench press Osteolysis of the distal clavicle (weightlifter’s shoulder) (12,18)
1. Military press
2. Upright row
3. Side raise
Soft tissue damage to the rotator cuff (mainly supraspinatus) and the long head of
the biceps at the shoulder origin inclusive of tendinosis, bursitis, tears, and
shoulder impingement (9,12,18,19,25,27)
1. Flat bench press
2. Behind the neck lat pull-downs
3. Military press
4. Chest fly/pec deck
5. Snatch
Anterior shoulder instability, glenohumeral capsular hyperlaxity, or dislocations
(9,12,28,32)
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shoulder disorders in the general and
athletic population, which is inclusive
of WT participants (30,32,34).
In a similar study (31), asymptomatic
females who participated in WT were
assessed for AROM, PST, glenohum-
eral joint laxity, bodyweight-adjusted
strength values, and agonist to antago-
nist strength ratios. The authors iden-
tified significant differences (p,0.004)
between the WT participants when
compared with controls when analyz-
ing shoulder internal rotation AROM,
PST, and glenohumeral joint laxity.
Specifically, the WT participants had
decreased internal rotation AROM,
greater PST, and an increased preva-
lence of anterior GH joint hyperlaxity
when compared with the control
group. No differences in strength ratios
between groups were identified (p,
0.109) suggesting the absence of WT-
induced muscle imbalances
among women.
A body of descriptive evidence has
suggested that WT participants may
be at risk for subacromial shoulder
impingement syndrome (also referred
to as subacromial pain syndrome),
hereafter referred to as impingement
syndrome (30). In the aforementioned
study, a clinical testing cluster for
impingement syndrome was per-
formed on 46 individuals who partici-
pated in WT and compared with 31
controls who had no history or WT
participation or sporting activities. Re-
sults of this study indicated that 20% of
WT participants were positive on a test-
ing cluster for impingement compared
with 5% of the controls (p,0.001).
Specifically, the testing cluster used
(Hawkins–Kennedy and positive pain-
ful arc sign) has been shown to have
a positive likelihood ratio of 5.0 for the
diagnosis of impingement syndrome
(40). A positive likelihood ratio of 5.0
suggests that individuals testing posi-
tive (pain during testing) are 5 times
more likely to have the condition as
opposed to having false positive results.
In the same study, exercise selection
was analyzed to determine if, indeed,
an association existed between the
prevalence of impingement syndrome
Figure 2. Pec deck exercise (high-five position-associated with shoulder injury).
Figure 3. Lateral deltoid raise to below 908angle.
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and routinely performed exercises.
Interestingly, those who performed
lateral deltoid raises above shoulder
height (908) or upright rows where the
elbows elevated above shoulder height
were more likely to have a positive
testing cluster as compared to those
who did not perform such exercises.
Furthermore, those who routinely
performed external rotator strength-
ening were less likely to present with
shoulder impingement.
In another study (34), WT participants
with shoulder impingement syndrome
(N524) confirmed by clinical exam-
ination using the same testing cluster
previously described, were compared
to WT participants without impinge-
ment syndrome (N531) to determine
differences in muscle performance and
mobility. Results of this investigation
indicated that WT participants with
impingement syndrome had reduced
shoulder internal and external rotation
AROM (,0.017) and decreased
bodyweight-adjusted strength values
of the external rotator and lower
trapezius musculature (p,0.03)
when compared to WT participants
without impingement. Furthermore,
bodyweight-adjusted strength values
of the upper trapezius were greater
among WT participants. In addition,
strength ratio imbalances were more
prevalent among WT participants with
impingement syndrome, suggesting
training bias with efforts to target the
larger upper trapezius and lateral del-
toid and with reduced emphasis on the
smaller stabilizing muscles such as the
external rotators and lower trapezius
(p,0.005).
In a study investigating the presence of
clinical signs of anterior instability and
hyperlaxity using previously validated
clinical testing (32), 123 WT partici-
pants and 36 controls were evaluated.
Researchers identified a greater preva-
lence of clinical signs and symptoms
of anterior glenohumeral instability
and hyperlaxity among the WT partic-
ipants when compared with the con-
trol subjects (p,0.005). In the
aforementioned study, the authors also
sought to determine whether there was
an association between clinical findings
and exercise selection. Results sug-
gested that those individuals with
shoulder anterior instability and hyper-
laxity were more likely to perform ex-
ercises in the “high-five” position
(Figures 1 and 2), defined as the
humerus in 908of external rotation
simultaneously with 908of shoulder
abduction. Moreover, individuals who
performed external rotator strengthen-
ing were less likely to have clinical
signs of anterior instability and hyper-
laxity. Although causative effects
should not be extrapolated from
descriptive studies using association
type data, trends that are biomechani-
cally plausible should not be over-
looked in the absence of prospective
investigations.
EXERCISES ASSOCIATED WITH
SHOULDER INJURY
There are specific WT exercises that
have been shown to place the shoulder
joint at risk. The Table summarizes
some of the exercises that have been
associated with injuries to the shoul-
der. Reeves et al. (41,42) suggested that
exercises placing the humerus in a posi-
tion of extension past the trunk could
contribute to anterior shoulder instabil-
ity and rotator cuff injuries. Similarly,
Haupt (19) associated osteolysis of the
distal clavicle with the bench press dur-
ing the eccentric phase of the exercise
when the humerus is extended poste-
rior to the trunk due to the repeated
microtrauma at the acromioclavicular
joint. Modifications to the bench press
such as placing a pad on the chest or
bar itself would limit the amount of
humeral extension that occurs past
the trunk (12,28).
There are other commonly performed
WT exercises that may place the
shoulder joint at risk. Exercises that
regularly place the shoulder joint in
the “high-five” position have been
identified as potentially hazardous to
the shoulder joint due to the increased
stress placed on the anterior shoulder
tissues (3,9,12,14,16). Placing the shoul-
der in this “high-five” position repeat-
edly with heavy loads may contribute
Figure 4. Upright rows with elbows raised to below 908angle.
Exercise Strategies to Mitigate Shoulder Injuries
VOLUME 00 | NUMBER 00 | MARCH 20 20
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Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
to hyperlaxity or instability to the static
glenohumeral ligamentous capsular re-
straints (4,12,16,19). Jobe et al. (24) sug-
gested that the dynamic rotator cuff
muscles likely exert a greater force to
stabilize the humeral head when hy-
perlaxity or instability occurs at the
shoulder. This repetitive dynamic com-
pensation of the rotator cuff may result
in fatigue followed by tendinosis and
pain in the rotator cuff.
Exercises in which the humerus is
internally rotated during shoulder
abduction may also put the shoulder
at risk for impingement. Researchers
have reported that avoiding the
upright row and lateral deltoid raises
beyond an angle of 908of shoulder
abduction could potentially decrease
the likelihood of sustaining shoulder
impingement (30). In agreement with
this statement, Hawkins et al. (20)
reported that if the arm is internally
rotated during elevation, the greater
tuberosity of the humerus pinches the
rotator cuff tendons and bursa against
the acromion.
Exercisessuchasbehindthenecklat
pull-downs (Figure 1) and the chest
fly-pec deck (Figure 2) are examples
where the high-five position occurs.
Modifying the chest fly-pec deck to
avoidtheendrangeandperforming
lat pull-downs to the front would be
reasonable modifications. Other rea-
sonable modifications to avoid some
of these positions would include lim-
iting lateral deltoid raises to below
908(Figure 3) and limiting upright
rows to a position where the elbows
are not raised above 908(Figure 4).
Readers desiring more detailed
information on WT modifications
to prevent and train around shoulder
pain are encouraged to review pre-
viously published articles in the
Strength and Conditioning Jour-
nal (8,12).
PREVENTIVE STRATEGIES FOR
SHOULDER INJURIES
Basedontheliteraturepresented,
muscular imbalances in the shoulder
complex exist and may contribute to
some of the shoulder injuries com-
monly encountered by WT partici-
pants as a result of training patterns.
To provide a logistic and effective
evidence-based program to
help minimize shoulder injuries, the
following information will be used as
a theoretical construct:
1. WT participants may have
increased external rotation as well
as decreased shoulder internal rota-
tion, flexion, and abduction AR-
OM (27,31).
2. WT participants are likely to
develop PST (27,31).
3. Strength ratios among male WT
participants indicate that larger
muscle groups (e.g., lateral deltoids,
upper trapezius, and pectoralis
major) are disproportionately stron-
ger than the smaller stabilizing mus-
culature (e.g., lower trapezius,
serratus anterior, and infraspinatus-
teres minor) (27).
4. WT participants who routinely per-
form external rotator strengthening
are less likely to present with shoul-
der impingement (30) and to have
clinical signs of anterior instability
and hyperlaxity (32).
5. Thoracic extension is a necessary
biomechanical requirement for
shoulder elevation, and both limited
thoracic extension and increased
kyphosis are associated with
reduced shoulder range of motion
and impingement (2,10,22,23,47).
The progressive exercise program
presented is based on the aforemen-
tioned range of motion deficits and
muscular imbalances as well as the
implementation of appropriate stabi-
lization exercises for the smaller mus-
cle groups that can be incorporated
into an overall strength training
program.
Figure 5. (A) Start of modified prone cobra; client positioned on stomach, arms by
side, and palms up toward ceiling. (B) Execution of modified prone cobra;
cue client to retract (pinch shoulder blades together) and depress scapula
(arrow identifies position of depression). While maintaining scapular
retraction and depression, the client is instructed to slightly extend the
thoracic spine (elevate chest off table) and reach fingertips toward toes to
assist with maintaining scapular depression.
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MUSCLE PERFORMANCE
The progressive approach to muscle
performance will present exercises de-
signed to target key muscles with an
understanding that correcting muscle
imbalances is a prerequisite to achiev-
ing higher levels of activation. Specifi-
cally, the lower trapezius, serratus
anterior, infraspinatus, and
teres minor musculature will be ad-
dressed with an approach that requires
early exercises designed to isolate the
aforementioned musculature. Isolation
will lend to mitigating imbalances.
Once isolation is achieved, then the
progression to more functional and
higher muscle activation exercises is
recommended. Premature progression
to exercises that maximally recruit the
desired musculature (as opposed to
isolation) may perpetuate muscle
imbalances.
LOWER TRAPEZIUS
The lower trapezius is a scapular
stabilizer and is responsible for
scapular depression. The goal for
addressing the lower trapezius ini-
tially includes exercises designed to
isolate the muscle without high acti-
vation of the lateral deltoids and
upper trapezius. The purpose of iso-
lating the lower trapezius without
concurrent recruitment of larger
muscles is designed to mitigate
shoulder imbalances. The initial
exercise performed for the lower
trapezius includes the modified
prone cobra (Figure 5A and 5B).
This exercise, when performed
appropriately, targets the lower tra-
pezius and minimizes activity of the
upper trapezius when compared
with more advanced exercises such
as the prone scapular Y (1). For the
modified prone cobra, resistance is
not a factor for loading as the goal
oftheexerciseistoperformthe
movement in a correct manner while
activating the lower trapezius
and minimizing recruitment of the
upper trapezius. Since this exercise
is focused on recruitment of the
muscle with proper technique and
there are no dosing guidelines for
this exercise, we recommend per-
forming this exercise daily using
hold times ranging from 10 to 30
seconds for 10 repetitions. Perform-
ing this exercise correctly will permit
the necessary recruitment. Once an
individual masters the ability to
recruit the lower trapezius accord-
ingly, the progression for strength-
ening the lower trapezius would be
the prone scapular Y exercise
(Figure 6A and 6B). This exercise is
a progression because it targets the
lower trapezius with maximal activa-
tion; however, it recruits the upper
trapezius and lateral deltoids as well
(1,11,13). For example, when deter-
mining muscle activity, electromy-
ography is used and the muscle
activation is often presented as a per-
centage of the maximum voluntary
isometric contraction (MVIC) acti-
vation. The MVIC is usually deter-
mined during an isometric muscle
action, which is then used to deter-
mine a dynamic activity’s percentage
of the MVIC. In the case of the prone
scapular Y, the lower trapezius is re-
cruited at 97% MVIC with the upper
trapezius at 79% MVIC and the lat-
eral deltoid at 82% MVIC (11,43).
Performing this particular exercise
before learning appropriate recruit-
ment of the lower trapezius may per-
petuate imbalances in the shoulder
because it recruits the lateral del-
toids and upper trapezius at fairly
high levels.
SERRATUS ANTERIOR
The serratus anterior serves to stabi-
lize the scapula and is responsible for
the scapular motions of external
rotation, protraction, and upward
rotation. The goal for addressing
the serratus anterior initially in-
cludes exercises designed to activate
the muscle without high activation
of lateral deltoids and upper trape-
zius. Like the modified prone cobra,
the purpose of isolating the serratus
anterior without concurrent recruit-
ment of larger muscles is also
Figure 6. (A) Start of prone scapular Y; client positioned on stomach on elevated
surface. (B) Execution of prone scapular Y; cue client to elevate arm in
scapular plane, thumb up, and elbow extended.
Exercise Strategies to Mitigate Shoulder Injuries
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Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
designed to mitigate shoulder imbal-
ances. The initial exercise performed
for the serratus anterior is the supine
punch (Figure 7A and 7B). The
punch isolates the serratus anterior
while minimally activating the upper
trapezius (11). When evaluating the
MVIC, one study indicated a 62%
MVIC of the serratus anterior with
a 7% MVIC of the upper trapezius
(11). Dosing for the punch exercise
generally would follow guidelines for
muscular endurance at 2–3 days per
week with repetitions in the 12–20
RM range with 30-second interset
rest periods. The progression of the
punch exercise would be the push-up
plus (Figure 8A and 8B) and ulti-
mately the upper cut (Figure 9A
and 9B). The push-up plus recruits
the serratus anterior at .73% MVIC
withlessthan50%MVICforthe
upper trapezius, whereas the upper
cut recruits the serratus anterior at
approximately 100% MVIC with
the upper trapezius at 66% (11,38).
Note that performing the upper cut
or push-up plus before learning to
recruit and isolate the serratus ante-
rior may perpetuate shoulder imbal-
ances. The push-up plus would be
dosed similar to the modified prone
cobra, whereas the upper cut would
be dosed within the guidelines rec-
ommended for the serratus punch.
Although the aforementioned exer-
cises provide a practical progression,
the serratus anterior is also activated
during overhead shoulder range of
motion. Further to this point, the ser-
ratus anterior activity is increased
with increasing ranges of shoulder
elevation (18). An additional
advancement to the previously men-
tioned serratus anterior progression
is to add the wall slide exercise
(5,18). This exercise requires the cli-
ent to place the ulnar aspect of the
hands in contact with a wall and slide
the hands up the wall (in the scapular
plane) while pushing into the wall.
An elastic band could be placed
around the wrists to increase the
challenge during elevation as shown
in Figure 10A and 10B.
INFRASPINATUS AND TERES
MINOR
The infraspinatus and teres minor
musculature serve as external rota-
tors and stabilizers of the glenohum-
eral joint. The goal for addressing
these muscles at first is isolation
with minimal activation of the ante-
rior and lateral deltoids. The first
exercise used for isolation of the in-
fraspinatus and teres minor includes
standing external rotation with elas-
tic tubing or a cable device (Figur-
e 11A and 11B). Standing external
rotation using elastic tubing or cable
in the 08abducted position recruits
the lateral deltoid at approximately
8% MVIC as compared to 50% MVIC
when the arm is in an abducted posi-
tion (39). Although not pictured,
external rotator strengthening may
be performed in the sidelying posi-
tion with comparable recruitment
patterns as standing with arm in
08abduction. Note that optimal form
for this exercise requires the use of
a small towel roll between the elbow
and side. Readers desiring a more
detailed explanation of the purpose
of using the towel roll are encour-
aged to review a previously pub-
lished article in the Strength and
Conditioning Journal (29). The pro-
gression of external rotation with the
arm adducted to the side would be to
perform the exercise with the arm
abducted to approximately 808as
showninFigure12Aand12B.Note
that this exercise activates the lateral
deltoids at a high level (50% MVIC as
compared to 8% MVIC with
08abduction) and would not be
appropriate to perform in the early
stages of a program because it would
perpetuate muscle imbalances. In
both of these exercises we recom-
mend dosing within the ranges dis-
cussed for the serratus punch.
Figure 7. (A) Start of serratus punch; client positioned on back, hand stacked on
top of shoulder, and elbow extended. (B) Execution of serratus punch;
provide resistance through band/dumbbell/kettlebell; cue client to
reach/punch towards ceiling while maintaining elbow extension; and
return to (A).
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POSTERIOR SHOULDER
TIGHTNESS
Because PST has been associated
with shoulder pain among WT par-
ticipants, efforts to address this
impairment should be part of a com-
prehensive program. The sleeper
and the cross-arm stretches are 2
stretches that can address PST and
may be used with their own progres-
sions. In both of these stretches, the
scapula should be stabilized to pre-
vent compensatory movement,
which will allow for better isolation
of the region (44). Stretching should
be performed daily for 3- to 30-sec-
ond holds. Readers desiring more
detailed information on the underly-
ing etiology and interventions for
PST as well as measurements de-
signed to quantify a mobility loss
are encouraged to review previously
published articles in the Strength and
Conditioning Journal (7,33).
SLEEPER STRETCH
The sleeper stretch can be per-
formed sidelying or standing. When
performed standing, the individual
stands against a wall with the lateral
aspect of scapula weight bearing
into the wall for stability as shown
in Figures 13A and 14A. We recom-
mend beginning with the arm ab-
ducted (elevated) to approximately
458(Figure 13A and 13B) and pro-
gressing to a 908angle as tolerated
for a greater stretch (Figure 14A and
14B). Note that the stretch involves
weight bearing into a wall to stabi-
lize the scapula while maintaining
the arm in either 45 or 908abduc-
tion. Once in this position, the oppo-
site arm is used to bring the
stretched arm into internal rotation
(toward the wall). For individuals
who have pain or discomfort at the
end range of the stretch, a lacrosse
ball may be placed at the posterior
shoulder as shown in Figures 13C
and 14C. Placing a ball in this loca-
tion will pin down the contractile
tissue and produce a stretch earlier
in the range.
Figure 8. (A) Start of push-up plus; client positioned in push-up position, cue to
retract scapula (pinch shoulder blades together). (B) Execution of push-up
plus; cue client to protract scapula (push floor away and protract [spread]
shoulder blades).
Figure 9. (A) Start of upper cut; client begins standing with arm by side. (B) Execution
of upper cut; cue client to protract scapula, adduct (ADD), and externally
rotate (ER) the humerus (elbow moves medially and hand moves laterally);
return to (A).
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CROSS-ARM STRETCH
The cross-arm stretch is an alternate to
the sleeper stretch. This stretch, similar
to the sleeper, involves stabilizing the
scapula against a wall. Once stabilized,
the arm is brought to a 908angle as
shown in Figure 15A. Once in position,
the opposite arm is used to passively
adduct the arm (cross-arm over body)
as shown in Figure 15B. Similar to the
sleeper stretch, a lacrosse ball may
(Figure 15C) be used as an adjunct to
the stretch and can be performed in
sidelying as a means of stabilizing scap-
ula. Stabilizing the scapula is a key ele-
ment of this stretch because evidence
suggests greater improvements in flex-
ibility when compared with a cross-
arm stretch without stabilization (44).
The choice of whether an individual
performs the sleeper or cross-arm
stretch should be based on comfort
because the sleeper stretch may be
painful among individuals with exist-
ing shoulder pathology. A body of evi-
dence among different populations has
indicated that the cross-arm stretch
may be more effective than the sleeper
stretch. Of importance to consider is
that one of these studies used a post-
operative population (45) and the
other (37) did not report clinically sig-
nificant differences. Furthermore,
a body of evidence suggests that there
are numerous options to improve PST
with multiple treatments (i.e., stretch
and soft tissue mobilization) being effi-
cacious when compared with a single
intervention (46).
THORACIC EXTENSION
Evidence has suggested that thoracic
spine mobility is needed for biomechan-
ically correct shoulder movements when
reaching overhead. In one study, it was
reported that during bilateral arm eleva-
tion, there was a mean increase of 11–138
of thoracic extension (10). Further to this
point, another study reported that in-
dividuals with impingement syndrome
had greater kyphosis and decreased
thoracic extension when compared with
an asymptomatic group (22). As a result
of these findings, ensuring adequate tho-
racic extension would seem reasonable as
Figure 11. (A) Start of shoulder external rotation (no shoulder abduction); client begins
standing, 6$towel roll between elbow and rib cage, elbow flexed to 908,palm
on stomach. (B) Execution of shoulder external rotation (no shoulder abduc-
tion); cue client to bring back of hand toward opposite wall, ending in slight
externally rotate (ER) past neutral; return to (A) under control.
Figure 10. (A) The wall slide exercise begins with the ulnar side (little fingers) of hands in
contact with a wall and a resistance elastic band around wrists. The individual
pushes hands into wall and begins to ascend up the wall (elevation of shoulder)
while maintaining pressure of hands into wall. During this phase, cues are
provided to ensure that pressure into the wall is maintained, and wrists are kept
at a distance against the resistance of the elastic band. (B) During the wall slide,
the goal is to slide up the wall (shoulder elevation) maintaining pressure and
keeping wrists apart. Pressure should be maintained into the wall during both
phases of exercise (shoulder elevation and during the return to A).
Strength and Conditioning Journal | www.nsca-scj.com 9
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
would correct thoracic posture during
overhead WT movements. In our expe-
rience, thoracic posture can be improved
through education; however, restricted
thoracic extension may be improved with
specific stretching exercises. One sug-
gestion for improving thoracic extension
in a fitness setting would be to sit
backward on a preacher curl device, so
that the arm pad is at the level of the
thoracic spine. Once in this position,
arching backward as shown in Figure 16
would increase thoracic extension range
of motion. An alternate stretch to increase
thoracic extension would consist of lying
supine on a foam roll positioned at the
thoracic spine while holding a kettlebell
overhead as shown in Figure 17. Stretches
maybeheldforadurationof30seconds
and repeated 3–5 times.
CONCLUSION
The shoulder complex is a commonly
injured body part among WT partici-
pants. Based on the current available
evidence, imbalances in the shoulder
complex exist and may contribute to
some of the shoulder injuries com-
monly encountered by WT partici-
pants; this may partly be due to
training practices. Evidence suggests
that WT participants may have
increased external rotation AROM as
well as decreased AROM for shoulder
internal rotation, flexion, and abduc-
tion AROM (27,31). Furthermore,
WT participants are likely to develop
PST (27,31) and male WT participants
Figure 12. (A) Start of shoulder external rotation (with shoulder abduction); client
begins standing, arm in 908ABD, 908elbow flexion, and cable anchored in
front of client at level of hips. (B) Execution of shoulder external rotation
(with shoulder abduction); cue client to bring back of hand toward the
ceiling until 90/90 position is attained; return to (A) with control.
Figure 13. (A) Start of stage 1 sleeper stretch; client standing with lateral aspect of scapula weight bearing into wall and arm to be
stretched at 458ABD with 908elbow flexion on wall. (B) Execution of stage 1 sleeper stretch; contralateral arm pushes
forearm and wrist of arm to be stretched into wall (achieving internal rotation) while maintaining scapular stabilization
through wall contact. (C) Progression of stage 1 sleeper stretch; add lacrosse ball at posterolateral shoulder while
performing stretch in (B).
Exercise Strategies to Mitigate Shoulder Injuries
VOLUME 00 | NUMBER 00 | MARCH 20 20
10
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
seem to have disproportionately stron-
ger larger muscle groups (e.g., lateral
deltoids, upper trapezius, and pectora-
lis major) as compared to the smaller
stabilizing musculature (e.g., lower tra-
pezius, serratus anterior, and infraspi-
natus-teres minor) (27). Finally, WT
participants who routinely perform
external rotator strengthening are less
likely to present with impingement
syndrome (30) and to have less clinical
signs of anterior instability and hyper-
laxity (32). Methodically addressing
the imbalances in the shoulder com-
plex that have been reported among
WT participants by implementing the
recommended exercises and progres-
sions may help to reduce the rates of
shoulder injuries among the WT pop-
ulation. Furthermore, modifying the
upper-body exercises that may predis-
pose the shoulder to injury and ensur-
ing proper technique/progressions are
implemented with all exercises may
further reduce the occurrence of inju-
ries to the shoulder region among this
population.
Figure 14. (A) Start of stage 2 sleeper stretch; client standing with lateral aspect of scapula weight bearing into wall and arm to be
stretched at 808ABD with 908elbow flexion on wall. (B) Execution of stage 2 sleeper stretch; contralateral arm pushes
forearm and wrist of arm to be stretched into wall while maintaining scapular stabilization through wall contact. (C)
Progression of stage 2 sleeper stretch; lacrosse ball at posterolateral shoulder while performing stretch in (B).
Figure 15. (A) Start of cross-arm stretch; client standing with lateral aspect of scapula weight bearing into wall. (B) Execution of
cross-arm stretch; contralateral arm pulls arm to be stretched across body through horizontal ADD while maintaining
scapular stabilization through wall contact. (C) Progression of cross-arm stretch: add a lacrosse ball at posterolateral
shoulder while performing stretch in (B).
Strength and Conditioning Journal | www.nsca-scj.com 11
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
Conflicts of Interest and Source of Funding:
The authors report no conflicts of interest
and no source of funding.
Guillermo
Escalante is an
associate profes-
sor of Kinesiology
at California
State University
San Bernardino.
Daniel Fine is
a doctoral stu-
dent in the
Department of
Physical Therapy
at Nova South-
eastern
University.
Kyle Ashworth
is a doctoral stu-
dent in the
Department of
Physical Therapy
at Nova South-
eastern
University.
Morey J. Kolber
is a professor in
the Department
of Physical Ther-
apy at Nova
Southeastern
University.
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This article provides a summary of the literature related to shoulder pain in strength athletes. The prevalence of shoulder injuries and types of shoulder injuries sustained will be reviewed. Exercises that may predispose strength athletes to shoulder injuries and suggestions of specific exercise modifications to reduce the risk of injury will be discussed. Finally, preventive strategies to reduce the likelihood of shoulder injuries will be addressed. For a video abstract describing this issue, see video, supplemental digital content 1, http://links.lww.com/SCJ/A199.
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Study design: Controlled laboratory study. Background: In scapular rehabilitation training, exercises that include a humeral elevation component in the scapular plane are commonly implemented. While performing humeral elevation, the scapula plays an important role, as it has to create a stable basis for the glenohumeral joint. However, a comparison of both deep and superficial muscle activity of the scapula between different types of elevation exercises is lacking and would be helpful for the clinician in choosing exercises. Objectives: To evaluate scapulothoracic muscle activity during different types of elevation exercises in the scapular plane. Methods: Scapulothoracic muscle activity was measured in 21 healthy subjects, using fine-wire electromyography in the levator scapulae, pectoralis minor, and rhomboid major muscles and surface electromyography in the upper trapezius, middle trapezius, lower trapezius, and serratus anterior muscles. Measurements were conducted while the participants performed the following elevation tasks in the scapular plane: scaption (elevation in the scapular plane), towel wall slide, and elevation with external rotation (Thera-Band). The exercises were performed without and with additional load. Possible differences between the exercises and the load were studied with a linear mixed model. Results: Performing elevation in the scapular plane with an external-rotation component resulted in higher middle trapezius and lower trapezius activity compared to the scaption and wall slide exercises. The upper trapezius was maximally activated during scaption. The pectoralis minor and serratus anterior showed the highest activity during the towel wall slide. The towel wall slide activated the retractors to a lesser degree (middle trapezius, lower trapezius, levator scapulae, rhomboid major). Adding load resulted in higher muscle activity in all muscles, with some muscles showing a different activation pattern between the elevation exercises, depending on the load condition. Conclusion: Scaption maximally activated the upper trapezius. The addition of an extra external-rotation component may be used when the goal is to activate the lower trapezius and middle trapezius. The towel wall slide exercise was found to increase pectoralis minor activity. Adding load resulted in higher muscle activity. Some muscles showed a different activation pattern between the elevation exercises, depending on the loading condition. The findings of this study give information about which elevation exercises a clinician can choose when the aim is to facilitate specific muscle scapulothoracic activity.
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Subacromial impingement syndrome (SIS) has been reported as an etiological source of shoulder pain among weight-training (WT) participants; however, a paucity of evidence exists to describe intrinsic risk factors. The purpose of this study was to investigate specific risk-related joint and muscle adaptations among WT participants identified as having SIS based upon a previously validated clinical testing cluster. Fifty-five men (mean age 27.3) who participated in recreational WT a minimum of 2-days per week were recruited, including 24 individuals with SIS and 31 without SIS serving as controls. Active range of motion (AROM), bodyweight-adjusted strength values, and strength ratios were compared between groups. Significant differences were present as WT participants with SIS had decreased internal and external rotation AROM (p ≤ .016), as well as decreased bodyweight-adjusted strength values of the external rotator and lower trapezius musculature (p ≤ .02), when compared to WT participants without SIS. Select strength ratios were greater in the SIS group (p ≤ .004) implying agonist to antagonist muscle imbalances. The impaired joint and muscle characteristics identified among WT participants with SIS are not without consequence, as they are associated with shoulder disorders in both general and athletic populations. Practical applications for these findings may reside in exercise prescription that addresses internal rotation mobility, mitigates training bias, and favors muscles responsible for stabilization such as the external rotators and lower trapezius. Strength and conditioning professionals should consider risk-related adaptations associated with WT when prescribing upper extremity exercises.
Article
Evaluate the effect of scapular stabilization during horizontal adduction stretching (cross-body) on posterior shoulder tightness (PST) and passive internal rotation (IR). Randomized clinical trial with single-blinding. Elite volleyball Club PARTICIPANTS: Sixty asymptomatic female volleyball players with GIRD INTERVENTIONS: Subjects were randomly assigned to either horizontal adduction stretching with manual scapular stabilization (n=30) or horizontal adduction stretching without stabilization (n=30). Passive stretching was performed for 3-30 second holds in both groups. Range of motion measurements of PST and IR were performed on the athlete's dominant shoulder prior to and immediately following the intervention. Baseline mean angular measurements of PST and IR for all athletes involved in the study were 62° (SD=14) and 40° (SD=10) respectively with no significant differences between groups (p=.598 and p=.734 respectively). Mean PST measurements were significantly different between groups following the horizontal adduction stretch with a mean angle of 83° (SD=17) degrees among the scapular stabilization group and 65° (SD=13) degrees among the non-stabilization group (p <0.001). Measurements of IR were also significantly different between groups with a mean angle of 51° (SD=14) degrees among the scapular stabilization group and 43° (SD=9) degrees among the non-stabilization group (p = .006). Horizontal adduction stretches performed with scapular stabilization produced significantly greater improvements in IR and PST when compared to horizontal adduction stretching without scapular stabilization. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.