Preventing Overhead Shoulder Injuries

Preventing Overhead Shoulder Injuries

Dave Thomas San Diego Performance360Written by Dave Thomas
Owner, Performance360

The shoulder is the most mobile, and also unstable joint in the body. Shoulders, their mobility, stability and health are a complex game as how well they function can be tied to a bunch of different areas. Our pecs, lats, traps, triceps and t-spine all play a role. Even our hips and ankles are contributors, as tightness in the base can set off a chain reaction in each joint along the way all the way to the top where an overhead grip can be disrupted. If any one area is particularly immobile or tight it will adversely effect shoulder function, and the last thing we want to do is create a shoulder injury when we’re working overhead.

Today is going to be a rather in depth look at the shoulder, and ways we can keep it healthy and setting us to work overhead for a long, long time.

Shoulder Articulations

The shoulder complex is generally described as containing four joints:

  1. The Glenohumeral (GH) Joint – Where your humerus (upper arm) meets your scapula (shoulder blade). This is the “ball and socket” joint that is the most mobile joint in the body. The GH joint is often the symptom of shoulder injuries, but rarely the cause. 
  2. The Scapulothoracic (STh) joint – Where the scapula moves on your ribcage. This is a very important area most commonly associated with injury prevention given its association with the scapula and all of the surrounding muscles. 
  3. The Acromioclavicular (AC) joint – Where your shoulder blade meets your collarbone. 
  4. The Sternoclavicular (SC) joint – Where your collarbone meets your sternum.

Requirements for Healthy Overhead Pressing

The ability to establish healthy pressing overhead requires the shoulder pass the following check points.

1. Have a Strong Foundation in the Lats and Core
Distal mobility requires proximal stability. A shoulder cannot function to it’s proper level without a strong core supporting it. This is priority number one.

If the muscles around the mobile shoulder GH joint are tight or weak, the GH joint will try and overcompensate for them and this is when you see compromised positioning and shoulder injury.

2. Thoracic Spine “Neutrality” → Full Shoulder ROM
Can’t be too flexed or extended, which will affect rib cage positioning, and ultimately limit shoulder mobility. With the shoulder, mobility comes first. Then, we add stability.

3. Stability in the Rotator Cuff
These muscles are critical for stabilizing the most unstable joint in the body (shoulder).

4. Balanced Scapular Muscles
The scapula and the humerus (upper arm) always move in coordination with one another. This is known as scapulo-humeral rhythm. They are a pair, so it’s important that balance in the musculature of the scapula exist, as to not create a faulty position of the scapular, which throws off shoulder movement and function. The scapula is also largely responsible for transferring force from the legs, to the upper extremities.

Here are the major movement patterns of the scapula.

Preventing Overhead Shoulder Injuries
(c) www.AceFitness.org

Elevation – Bringing the scapula closer to the ears (ie shrugs, cleans)
Depression – Moving the scapula away from the ears (ie pull-ups)
Retraction/Adduction – Moving the scapula towards the spine (ie rows)
Protraction/Abduction – Moving the scapula away from the spine (ie push-ups)
Upward Rotation – Moving the scapula up and away from the spine (ie overhead press, side raise)
Downward Rotation – The return motion of upward rotation.

Certain gym movements are more dominant towards a specific action of the scapula.

  • Pressing – Scapular Protraction
  • Overhead Pressing – Upward Rotation
  • Rowing – Scapular Retraction
  • Pulling Up – Scapular Depression
  • Shrugging – Scapular Elevation

As you can see, if you are too dominant in a few areas without creating balance, you run the risk of hard-wiring only a few scapular movements, which will likely lead to an imbalance of muscle development in the scapula. This can work it’s way into the joints of the shoulder and cause injury or faulty movement pattern.

Beginners and Overhead Work?

One of the primary reasons we do not take beginners and immediately overhead press them with the fixed shoulder position of a barbell, is they often lack all four of those requirements (strong core, thoracic mobility, strong rotator cuff, balanced scapular stabilizers). In reality, we would love months and months to develop and reverse poor shoulder posture and function, but we do the best we can with what new athletes will give us.

Let’s break down all four requirements.

#1. Strong Foundation in the Lats and Core

Remember the phrase distal mobility requires proximal stability. Refer to our article on both the lats and the core to better understand why they must be performing optimally for the shoulder to in turn perform optimally. 

If you don’t feel like reading them, then understand that weakness in your lats and anterior core will never produce a properly functioning shoulder.

#2. Thoracic Spine: The Importance of Proper Rib Cage Positioning

The human body is one large complex interaction and interdependence between various parts. This is very evident when looking at the shoulder complex and the thoracic spine. Healthy overhead positioning starts in the thoracic spine, particularly, whether or not the T-spine can extend will have great impact on rib cage position.

Rib cage position is very important to shoulder health, because if the rib cage position is faulty, then it is simply not possible for the scapulae, and the humerus (upper arm bone) to to avoid that line of fault when moving under load.

The humerus and the scapula always move in cooperation with one another, known as “scapulo-humeral rhythm”.

So, as we move forward remember the important connection between the rib cage, the scapula, and the shoulder.

Too Much Thoracic Flexion

The athlete must be able to extend their T-spine in order to enjoy healthy overhead pressing. Think about it like this. If an athlete cannot extend, it means they are “locked in” a position of too much rounded flexion (that upper bunch back look).  It is only common sense to know that a shoulder, which sits on top of that rounded position, cannot move free and easy in its normal range, right?  That flexed T-spine has messed with the natural order of the scapulo-humeral rhythm.

Preventing Overhead Shoulder InjuriesT-Spine Stuck in Flexion                                     T-Spine with Healthy Extension

When this flexed T-spine is left to persist, a few bad things may ultimately happen.

Upper Crossed Syndrome

This is the condition described above, commonly referred to as the “Computer Desk Disease”, but it has also been called “Bro Syndrome” because of it’s association with too much bench pressing.

Preventing Overhead Shoulder Injuries

Essentially, it is a condition where our pecs, biceps, and upper traps become tight/overactive (remember this concept from Lower Crossed Syndrome), and in combination with certain weak scapular muscles being weak/underactive (serratus anterior, rhomboids), our shoulders are “pulled” forward by our over-active muscles…and we become hunched.

Upper Crossed Syndrome results in the athlete resting in passive internal rotation of the shoulders and protracted scapula. This is the largest precursor to shoulder injury.

Once Upper Crossed Syndrome develops, the next step can be injury in the form of shoulder impingement and/or low back pain.

Preventing Overhead Shoulder InjuriesUpper Crossed Syndrome                                                                   Good Posture

Shoulder Impingement

When a weak rotator cuff is consistently overpowered by strong front deltoids (as is the case with too much pressing and not enough pulling, for example), the natural, healthy space between the acromion process and ball of the humerus shrinks. The bursa becomes “impinged” and the tendons underneath become inflamed and irritated. If unaddressed, this can lead to tears.

This is the most common shoulder injury in the gym setting, and the exact reason we do not high rep overhead press. Clinical studies have shown that a fatigued rotator cuff can cause the humeral head to shift, which narrows the subacromial space and increases the likelihood of impingement.

Low Back Pain

If we somehow manage to escape shoulder impingement, it likely means our lumbar spine has becoming accustomed to going into hyperextension to “jump on the grenade”. In the absence of mobility in a joint, it is always the surrounding joints that come to aid and hypermobilize. In this case, because our thoracic spine would not mobilize, the lumbar spine right beneath it did so that our shoulder move free enough to complete the overhead motion.

We see this commonly when athletes will have an excessive arch in their low back when overhead pressing.

Upper Crossed Syndrome is the precursor to impingement and low back pain. We can help prevent that by establishing good posture during the day and by proper activation of the soft tissue of the shoulder, which we will address next.

Exercises for Thoracic Extension

Bar Pass Overs
This will not train thoracic extension directly, but the act of lengthening the pec minor and major will reduce that forward hunch and pull on the humerus. This will result in more extension ability in the T-spine.

Bar Dislocates

Overhead Squat
At just a PVC pipe, the OH Squat can be a great tool even for those who cannot get into the position safely under a barbell.

Snatch PVC OHS Test

Foam Roller Extensions
We prefer to support the head of the athlete with a vertical foam roller placement.

Keeling Thoracic Rotations
Try to keep the pelvis squared to the floor and only rotate in the thoracic spine. We do not want the lumbar to do the rotating here (or really, ever).

Kneeling Thoracic Rotations

#3: Stability in the Rotator Cuff

shoulder_anatomyThe rotator cuff provides the necessary soft tissue help to stabilize a very unstable structural set-up in the shoulder.

Your rotator cuff and your labrum are often confused as the same thing, but they are very different. The labrum is a small piece of fibrocartilage that is located in the rim of the shoulder socket that helps keep the ball of the joint in place. The rotator cuff consists of four small muscles that originate from the scapulae and connect the humeral head to the shoulder socket.

The rotator cuff consists mainly of four small muscles and is very important to the shoulder’s function.

  • Supraspinatus
  • Infraspinatus
  • Teres Minor
  • Subscapularis

The reason why a strong rotator cuff is important, is because a weak cuff will easily become overpowered by a strong front deltoid. Over time, this leads to the exact imbalances we want to avoid (internally rotated humerus, protracted scapula).  

Preventing Overhead Shoulder Injuries

In addition, there is what’s called the weakest link theory at play, and that is, once a muscle group becomes your limiting factor, progress stops. Your body will literally not allow itself to continue to get stronger and develop when a weak leak persists, as a way of protecting itself from injury. And in a lot of instance, weak muscles responsible for joint stability are the biggest culprits, ie. the rotator cuff.

There are training anecdotes from renowned strength coaches who claim to increase an athlete’s bench press by up to thirty to fifty pounds simply by including external rotation into their program, as a way to remove the limitations of strength stability in the shoulder that was inhibiting progress.

So, the rotator cuff plays a very big role in maintaining law and order in the scapulo-humeral rhythm.

Strengthening the Rotator Cuff

External Rotations
Try to keep the elbow pinned by the side as close as possible.

External Rotations Preventing Overhead Shoulder Injuries
Handcuff Pulls
Handcuff Pulls Preventing Overhead Shoulder Injuries

Scapular Plane Raises
This is the natural plane of the scapula, about 30–45 degrees in front of the frontal plane (side raise). Maintain a thumbs up, neutral grip. As with any raise, make sure not to shrug at the top. Shrugging turns it into a trap exercise.

Scapular Plane Raises Preventing Overhead Shoulder Injuries
I do not own, nor know the original owner of this image.

#4: Balanced Scapular Muscles

Remember, we want to keep the scapula out of passive protraction and the shoulders out of hunched internal rotation (Upper Crossed Syndrome). Most of the abnormal biomechanics and overuse injuries that occur within shoulder girdle can be traced to alterations in the function of the scapular stabilizing muscles.

When we say “balanced”, what we mean is avoiding the dysfunctional development of the Tight/Overactive muscles dominating the antagonist Weak/Inhibited muscles.

Scapular Muscles Preventing Overhead Shoulder Injuries

The muscles of scapular stability that we want to focus on are:

Serratus Anterior – The primary role of the serratus anterior is to stabilize the scapula during elevation (overhead pressing) and to protract the scapula (push-up, bench press). This is considered to be the most commonly weak muscle of the group because it is very difficult to target.

Rhomboids – The rhomboids are very active in scapular retraction (rowing). We cannot achieve full scapular retraction with weak rhomboids.

Weakness/Inhibition of the Serratus Anterior and Rhomboids is closely associated with Upper Crossed Syndrome.

Trapezius – The traps are a large muscle group in three parts: upper, middle, and lower traps. The upper part is responsible for elevation (hang clean). The middle traps retracts the shoulder blade (rowing). The lower trap contributes to scapular depression, drawing it down and in toward the spine (pull-up). Because they are so big, overdeveloped upper traps can often take over movements and create scapular imbalance, as well as low back pain.

Levator Scapulae – Scapular elevation. This muscle gets tremendous overwork for athletes who focus on “shrug” heavy movements like weightlifting, and who allow their shoulders to elevate on movements where they shouldn’t.

Pressing overhead is a coordinated effort between the upper trap, lower trap and serratus anterior. An overactivation of the upper trap when moving overhead has been shown to be a major contributor to shoulder dysfunction.

Activating the Scapular Muscles

These drills will help target the underdeveloped rhomboid, middle and lower trap.

Banded Retractions
Focus on initiating and finishing the row with retraction of the scapulae.

Banded Retractions Preventing Overhead Shoulder Injuries

Wall Slides
With the feet about 8-12” away from the wall, place your hips, T-Spine and head in contact with the wall. Then, in a W position, establish contact with the elbows and wrists. Slide them up the wall until the elbows extend, keeping wrist and elbow contact the entire time. If the athlete cannot maintain contact, complete ROM up until contact is lost.

Wall Slides

Protracted Push-Ups
Slight protraction at the top of every push-up rep is a good habit to establish, as it will target the serratus anterior. If we focus on retraction of the scapulae the whole time, the serratus won’t get worked.

Protracted Push-Ups Preventing Overhead Shoulder Injuries

MB Push-Up – By placing a hand on a MB, the opposite arm will have increased ROM, which means at elbow extension, the shoulder will experience further ROM in the protraction and will target the serratus.

Medicine Ball Push-Ups Preventing Overhead Shoulder InjuriesThe longer arm gets more protraction at extension, thus targeting the Serratus Anterior.

Making Sense of it All

To massively oversimplify this, what this looks like is an athlete who likely:

  • Pushes more than they Pull.
  • And/or, Pushes with bad mechanics.
  • i.e., doesn’t activate the scapula in push-ups by briefly “rounding at top”
  • Overhead presses with bad thoracic mobility
  • And/or, Pulls with bad mechanics.
  • Always start any row with retracting the scapula BEFORE flexing the elbow. This will turn on the rhomboids.
  • Always start pull-ups by depressing the scapula (aka finding “Giraffe” position)
  • Never shrug at the top of a deadlift.
  • Think “row low” and depressing the scapula, not shrugging and elevating it. Rowing should not involve a shrug.
  • Allows their Upper Traps to take over when they shouldn’t.
  • i.e. elevating the shoulders on rear delt raises, deadlifts, kettlebell swings, and barbell rows
  • Develops and reinforces bad posture (aka thoracic flexion) on a daily basis.
  • i.e. sits at computer, looks down on phone

Beneficial Movements in the Gym

The following are part of our daily training that are opportunities to improve shoulder function, generically speaking.

  • Bottom’s Up Work – Bottom’s up KB work is great at bridging the gap between strength and stability. Athletes who are very strong in the overhead press family should also be able to move relatively impressive weight in the bottom’s up press, where stability and motor control reign supreme. When performing unilateral pressing, always “swing out” a bit (middle image). It will put the scapular and shoulder into a better position.  
  • High Plank Side Bridges – An excellent movement for scapular stability.
  • Russian Kettlebell Swings – The rotator cuff works to keep the humeral head in its socket on every rep.
  • Push-Ups (Correctly) – Make sure all push-ups end with slight scapular protraction to ensure the scapula is playing a role in stability.  
  • Turkish Get-Ups or Turkish Sit-Ups – Builds strength and stability in the rotator cuff.
  • Farmer Walks & Deadlifts – This is literally your rotator keep keeping your arm in its socket. They also both retract and depress the scapula, something most of us want more of.
  • Rear Delt Raises w/ Pronated Grip – This builds the underactive rear delt that often gets bullied by the biggers, stronger traps.
  • Quadruped Movement – Helps build thoracic mobility and shoulder stability, via working the muscles of the scapula.
  • Ring Rows – Our easiest and most basic form of scapular retraction.
Important Takeaways

  • Proper positioning in the thoracic spine, core strength, rotator cuff stability, and balance in the scapular stabilizers are pre-reqs for successful shoulder function.
  • Too much sitting and hunching, in combination with bad gym movement can lead to Upper Crossed Syndrome. 
  • Through improper gym movement and a lack of well-rounded programming, we can develop and reinforce Tight vs. Weak musculature that precursors injury. 
  • Encourage athletes not to cherry pick. It’s important to include all forms of scapular function across multiple planes of movement. 
  • Always encourage lighter overhead load performed properly as opposed to heavier load with a struggle. Do not add strength to dysfunction. 
  • Avoid overhead pressing athletes who display poor thoracic mobility (as usually evidenced by an elevated rib cage).

Hopefully this provided a glimpse into the world of the shoulder and how you can better set yourself up to be healthy and successful.

Agree? Disagree? Let me know what you think, and if you liked it, please hit the SHARE button below. 

References:

Moseley JB Jr, Jobe FW, Pink M, Perry J, Tibone JE. EMG analysis of the scapular muscles during a scapular rehabilitation program. Am J Sports Med. 1992;20:128–134 [

Kuhn JE, Plancher KD, Hawkins RJ. Scapular winging. J Am Acad Orthop Surg. 1995;3:319–325

Paine, Russ, and Michael L. Voight. “THE ROLE OF THE SCAPULA.” International Journal of Sports Physical Therapy. Sports Physical Therapy Section, 1 Oct. 2013. Web. 31 Jan. 2017.

Paul, Andrew. The Strength Coach’s Guide to Shoulder Training (n.d.): n. pag.Www.thestrengthcoach.com. 2009. Web.

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