Dr. Jeffrey Tucker
11600 Wilshire Blvd. #412
Los Angeles, CA 90025
A thirty-year-old male personal trainer presented with right shoulder pain. He is well built and exhibits the body of a weight lifter – small waist, big broad shoulders with well-developed chest and arm muscles. He has a history of overuse injuries from weight lifting. He initially presented to my office with inflammatory symptoms and tenderness to palpation of the right biceps tendon, supraspinatus muscle/tendon, and anterior deltoid muscle. The subacromial space felt decreased and was tender to palpation. He had pain with resistive tests for the same muscles. Resisted flexion caused pain at the bicipital groove. He exhibited a painful arc in external rotation and abduction. These muscles and tendons are most likely the site of the source of pathology and his symptoms. His working diagnosis was tendinitis and impingement syndrome.
The serratus anterior and lower trapezius muscles test 3/5 and are unable to withstand resistance applied throughout the range. The upper trapezius muscle tests are 4-/5. There is tightness of the pectoralis minor. This allows uncontrolled scapula forward tilt, which is associated with shoulder ‘impingement’ type symptoms. Most repetitive micro-trauma shoulder complaints are related to uncontrolled movement of either the scapula or humerus. These may present as dysfunction of articular motion associated with abnormal myofascial structures.
Because this client is a personal trainer, it made it more important for his shoulder rehab and retraining to identify the necessary modifications in terms of weight lifting techniques. The first part of his rehab program was to design a workout repertoire that started with foam rolling the overactive latissimus dorsi and pectoralis minor. After foam rolling he was instructed to stretch the tight pectoralis minor and latissimus dorsi. After stretching he was taught to focus on core stability. I made sure he was integrating low threshold recruitment of local and global muscle systems. He is used to high threshold strength training of the global stabilizer and global mobilizer muscle system.
Review of normal shoulder biomechanics and scapulohumeral rhythm:
During flexion & abduction of the humerus, there s a 2:1 ratio of movement in the humerus to the scapula, with 120 degrees occurring at the GHJ & 60 degrees at the Scapulo-thoracic joint. There are 3 phases:
- In the first 30 degrees the outer end of the clavicle elevates 12 to 15 degrees while the scapula is “setting”
- During the next 60 degrees the clavicle will elevate 30 to 60 degrees & there will be a 2:1 ratio of scapulohumeral movement
- During the final 90 degrees of motion there continues a 2:1 ratio & the clavicle rotates posteriorly 30-60 degrees. The movement of the scapula on the thorax allows the glenoid fossa to follow humeral head motion thus maintaining a consistent length-tension relationship among the muscles of the GHJ. There is a force-couple relationship between the serratus anterior and upper and lower trapezius for scapula rotation. During full elevation in abduction the humerus must externally rotate (glide caudally) for the greater tubercle to clear the coracoacromial arch. If this does not occur it may lead to impingement.
The joint capsule must have the appropriate flexibility and the rotator cuff muscles must be functioning properly to bring the head of the humerus down and in (compresses and downward translation). There is another force-couple relationship between the rotator cuff and deltoids. When stability of the scapula is lost, the deltoid becomes less efficient, rotator cuff stabilizing strength is decreased, and the humerus elevates superiorly leading to suprahumeral impingement.
Movement impairment criteria: This patient displayed faulty movement of the
humeral head in the GH joint. The treatment plan was to reduce his symptoms, the corrective exercise rehabilitation plan was to correct his faulty movement.
What is normal alignment of the humeral head? Less than 1/3 of the humeral head should protrude in front of the acromion; neutral rotation should be present; the antecubital crease faces anteriorly; the olecranon faces posteriorly; the proximal and distal ends are in the same vertical line.
Post Rotator Cuff Injury & Impingement (Tendonitis) Rehab. The acute phase and pain reduction was managed with the Deep Muscle Stimulator (DMS), Class IV Laser, and mobilization.
Specific weight lifting exercise modifications for clients with shoulder injuries:
• Narrow hand spacing
– No wider than 1.5 times biacromial width
– Minimizes peak shoulder torque while pressing
– Reduces anterior/posterior rotator cuff and biceps tendon requirements for humeral head stabilization
– Maintains shoulder abduction to less than 45 degrees
– Decreases compressive forces at the distal clavicle
Additional Recommendations for the Bench press
• Maintain shoulder extension at less than 15 degrees
• The bar “touch” point is superior to the xiphoid process, decreasing the net torque on the shoulder
• Overhand grip (pronated position)
– Internal rotation moves biceps tendon from under acromion
– Positions supraspinatus muscle portion of RC beneath the anterior acromion
• Underhand grip (supinated position)
– Places long head of biceps under the acromion during the pressing motion
– Supraspinatus is rotated posteriorly, away from the acromion
• NO INCLINE BENCH PRESS
– Places person in “High 5” shoulder position (90 degrees of shoulder abduction and 90 degrees of shoulder external rotation (instability).
– Places increased stress on anteroinferior & anterior shoulder instability with increased strain on middle & inferior glenohumeral ligament complex
Bench press: posterior shoulder instability
• Increase hand spacing to more than 2 times the biacromial width
• This wide grip
– Structural approximation of the humeral head in the glenoid fossa
– Decrease strain on the posterior shoulder
– Shoulder abduction of greater than 80 degrees
• NO DECLINE BENCH PRESS
– Keep the angle between the arms & forearms at 80 degrees abduction.
– Wide bar grip
– Horizontal abduction of greater than 15 degrees at start of concentric phase of lift
– Horizontal adduction less than 20 degrees at finishing position
– Mandatory “handoffs” for all lifts
Behind the neck press is not allowed. The physiological effects of this exercise can be replaced with: Rear deltoid raises, Seated rows, and/or Dumbbell rows.
Front Shoulder Press is performed in the scapular plane.
• Hands placed slightly wider than shoulder width
• Bar rests on anterior deltoid muscles & SC joint
• Final bar position is directly overhead with arms in line with both ears
• These are the precautions for the front shoulder press: Horizontal translation (path) of the bar is anterior to posterior during the lift. Increased strain on inferior GH ligaments. Increased risk of GH subluxations by increased external rotation as the exercise concludes.
• The modifications for the front shoulder press: Use of Power Rack (weight on the bar)
• Seated Isometric presses at a progression of:
– 60 degrees of flexion
– 90 degrees of flexion
– 120 degrees of flexion
– 6 to 10 reps each angle
– 5 second “isometric” hold for each rep
• Shoulder press “lock outs”
– Limited weight
– Reduced stress to shoulder and low back (no arching)
• Limited shoulder ROM
• Teaches technique of UE in line with the ear at completion of the exercise and avoids excessive shoulder flexion/ER
LATS PULL DOWN
The latissimus dorsi pull down is not performed behind the neck.
The modified trunk position is seated with 30 degrees of trunk extension.
Bar grip of 1.25 to 1.5 times biacromial grip.
Exercise begins from overhead to slightly above the xiphoid process.
Emphasis is placed on scapular retractors and latissimus dorsi muscles.
Front pull avoids High 5 position and negates stress on inferior GH ligament complex. The front pull also has a greater mechanical advantage for lat insertion (EMG analysis).
Do not use a incline type bench (bench with a back) when performing the lats pull down. This would assists fixation of scapula and may inhibit normal scapular/humeral rhythm
The Power Clean is a total body exercise. It has high power output (up to 6 HP). The exercise is performed in less than 1 second with initiation of the legs and a transfer of force/power to the upper extremities. The Power Clean is sports specific, and it trains muscles that provide scapula stability.
Power Clean Precautions: Repetitive motion (“catching” the bar) places possible risk of “microtrauma” to distal clavicle and wrist joint. SLAP Lesion at risk during acceleration and deceleration phases of the exercise.
The Power Clean modifications include pulls instead of cleans. The wrist remains in neutral position; No AC joint microtrauma.
SLAP Lesions: Perform from “Hang” position vs. floor; Use bumper plates to eliminate bar deceleration; Reposition prior to each lift.
The Back Squat requires the upper extremity to be in an abducted and externally rotated position (High 5 position). This may be fine with some clients (i.e. pitchers and not with others i.e. linebackers). The common modifications include:
The Buffalo bar decreases both abduction and external rotation. The grip should be wider to decrease ABD & ER.
Another modification is the Front squat. I use the Kettlebells for these. They actually provide a safer “environment” for the shoulder because it remains adducted.
Sahrmann SA 2002 Diagnosis & Treatment of Management Movement Impairment Syndromes. 1st Mosby, USA.
Kendall FP, McCreary EK, and Provance PG 1993 Muscle Testing & Function, 4th Edition, Williams & Wilkins.
Price et al. 2000 Active and passive scapulohumeral movement in healthy persons: a comparison. Arch Phys Med Rehabil 81:1 28-31.
Comerford, M. Course lecture notes 2007, 2008, 2009.
All the coaches and trainers I have worked with over the years.
Dr. Jeffrey Tucker, D.C., D.A.C.R.B, is a rehabilitation specialist, author, lecturer, and healer best known for his holistic approach in supporting the body’s inherent healing mechanisms and for integrating the art and science of chiropractic, exercise, nutrition and attitudinal health. He instructs for the National Academy of Sports Medicine and the Chiropractic Rehabilitation Association. He practices in West Los Angeles, CA. For more information, please visit: www.drjeffreytucker.com.