MODIFYING WORKOUTS FOR ATHLETES WITH PAIN

Horizontal Pushing

• Shoulder • Wrist

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Subacromial impingement syndrome is certainly a player in horizontal press variations. This can occur due to all of the reasons we discussed in the shoulder pain section with vertical pressing. The angle
of pressing changes with horizontal pressing and because of that the forces on the shoulder are a bit different than overhead pressing but otherwise similar. Ultimately we’re going to need more rotator cuff strength and endurance.

What’s new in this chapter will be in the discussion of how certain positions of the shoulder can lead to impingement.

Positional Impingement of the Shoulder

Compression of the subacromial contents can occur due to lack of control from the rotator cuff but
also due to the position of the shoulder blade and joint. This can occur from a lack of scapular control and strength as well as from mobility restrictions. Where we see this most often is in movements that require a lot of range of motion like a dip. Dips require a lot of extension of the shoulder joint to perform properly.

Chest up, shoulders back, extended spine Shoulders rolled forward, upper back rounded, elbows ared out

Horizontal Pressing and Shoulder Pain

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If an athlete is missing extension range of motion at the shoulder we see several compensations in the bottom of the dip:

• Forward inclined torso
• Limited depth
• Excessive thoracic rounding
• Scapular anterior tilt
• Elbows air out (Shoulder internal rotation)The same can occur in the bottom of a pushup as well.

  Shoulder Health Side Note

  Pushups require much less shoulder extension then a dip. You’d have to be very immobile to com- pensate in a pushup due to mobility restrictions. Because of this, most people that compensate in the pushup do it because of a lack of shoulder strength and stability. Learn more about this in the sections below.

  Let’s delve into why this is bad from a shoulder health perspective. In the bottom of a dip as we run
  out of shoulder extension motion, we begin making this up with scapular anterior tilt, shoulder internal rotation (elbows air out) and thoracic exion. Basically the upper back rounds and the shoulders roll forward.
  Thoracic exion coupled with scapular anterior tilt will bring the acromion down toward the humerus. This decreases the subacromial space impinging upon shoulder structures. Internal rotation of the shoulder brings the greater tuberosity closer to the acromion further increasing impingement. So far, this isn’t looking too good but it’s not over yet.
  Based on our understandings of joint arthrokinematics we also know that extension of the shoulder will drive the humerus forward. In the bottom of a dip we’re driving the shoulder into end range extension thus pushing the ball forward in the socket. If the rotator cuff is not adequately controlling motion in the joint we may get even more forward motion of the ball in the socket. Given all of the factors we just dis- cussed it’s little wonder that the front of the shoulder can get painful sometimes in people doing dips.

  ***Shoulder Health Side Note

  Think about the structures that lie in the front of the shoulder. The main area that comes to mind is the long head of the biceps tendon. The long head of the biceps is anatomically prone to dysfunction. The long head of the biceps tendon sits inside the bicipital groove, giving it less access to blood supply. The long head of the biceps tendon (Pictured in red below) also makes
  a sharp turn as it leaves the bicipital groove on the way to it’s origin (The supraglenoid tubercle). Because of this angle of pull the tendon may be more prone to pathologic changes over time (Tendinopathy). Biceps tendonitis has been shown in the medi- cal literature to be associated with rotator cuff tears, particularly the subscapularis. It makes sense, one of the main jobs of the subscapularis is to prevent forward translation of the humeral head (the ball coming forward in the socket). If the rotator cuff (the subscapularis in this example) is not working properly, the long head of the biceps can be compressed and take more stress.

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It’s not all about mobility

We just made a big stink about limited mobility lending to shoulder problems in the dip. However, athletes don’t have to have limited mobility to end up in poor positions when performing dips, pushups, kipping and muscle-ups. Remember the pushup example earlier in this section. We see athletes all of the time that nd themselves in poor positions in the bottom of dips and pushups and have no mobility restrictions at all. Keep in mind that athletes will default to poor positions for a multitude of reasons:

1. Attempting to nd ideal length tension relationships of muscles

1. Muscles tend to be strongest when they aren’t either fully stretched out or fully shortened. Some- times our technique re ects our body trying to nd the strongest position of a muscle to produce force.
2. Example: Athletes may incline their torso forward in a dip because it puts the pecs and anterior delts in a stronger position to produce force

2. Utilizing passive stability of the shoulder to improve strength

1. The shoulder capsule (mainly the inferior and middle glenohumeral ligaments during shoulder ex- tension) provide a lot of stability in the shoulder joint while performing shoulder intensive movement. Sometimes our body’s will adopt certain positions to best utilize the stability of these structures. Think of relaxing into the bottom of a dip. The shoulder capsule is going to help prevent movement in the shoulder when the muscles are not active. Theoretically the capsule will take more stress if the musculature supporting the shoulder is not strong enough or if the musculature fatigues before the set is complete. Just keep in mind that relying on this system excessively may lead to stretching of the structures and instability of the joint.
2. Example: Athletes may reach their shoulder forward in the bottom of a pushup to gain stability from the shoulder capsule and get a few more reps

3. Defaulting to prior strongest motor patterns

1. If you’ve spent years performing a given movement in a speci c way you build muscle memory around your technique. Your body gets strong performing this movement in the way you’ve prac- ticed. The trouble is, sometimes the technique we’ve practiced for years is not the best from a performance or joint health perspective. Making a change is going to require lowering the weights used on a given lift or regressing the dif culty of the movement until we’ve built strength in a better position.
2. Example: Some athletes may air their elbow out wide on pushups because that’s they way they’ve always trained pushups and it’s currently their strongest position

4. Never being coached on optimal biomechanics

1. Sometimes it’s as simple as never having a good coach to cue you how to move properly. In this case after a few cues the movement is stronger and safer.
2. Example: A few cues for elbow position during bench press may make the athlete feel immediately stronger and can complete more reps during a given set.

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Mobility is step #1

If someone lacks range of motion at a joint then the rst step is to improve this. This goes for all other movements as well, not just horizontal pressing. We won’t be able to learn proper motor patterns, tech- nique and build strength and stability if we don’t even have the mobility to get into the right positions. Keep in mind that after someone improves their mobility it doesn’t mean they’ll automatically improve their technique. Chances are they’ll default right back to their old habits once the exercise becomes too challenging. We still will need to continue cueing and correcting our athlete’s movement and chances are we’ll also have to regress the exercise dif culty to where technique can be solidi ed. Then we can slowly progress our athletes back to the more challenging movements (Ring dips, Muscle-ups etc.)

5 Steps to Success

1. Full range of motion – Full joint and muscle mobility in all areas required to perform a motion properly
2. Learning ideal positions – Building ideal technique and motor control with low level easy to perform movements
3. Slowly loading ideal positions – Building strength and stability in proper positions
4. Transfer to more complex motions (Muscle-ups, ring dips)
5. Build endurance for carry-over into met-con

Correcting Dip Problems

1. Pec Major / Minor, Anterior Deltoid, Thoracic Spine Mobility
2. Positional Correction Drills

1. Tabletop
2. Assisted Dips
3. Crab Walks
4. Muscle-up Transition Drills

3. Loading P-bar and Ring Dips

1. Tempo (Slow lower)
2. Paused Reps (in bottom of dip)

4. Muscle-ups, Front Uprise
5. Introduction of fatigue with these movements

Tabletop movement

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Correcting Pushup Problems

1. Regress pushup dif culty and coach optimal shoulder blade position

Subacromial impingement syndrome is an issue with horizontal pressing variations but not always in the same way as with overhead pressing. (For a primer on subacromial impingement syndrome see the section on overhead pressing and shoulder pain) Here’s why.

Varying Angle, Grip and Bar to Alter Pain

Sometimes when we modify our grip (narrow vs. wide), change the angle that we press (incline press vs at bench press) or change the barbell (neutral grip vs regular bar) we can eliminate pain when pressing.

When we change the angle or barbell we’re also stressing the shoulder in a slightly different way. May- be a sensitive part of the rotator cuff is no longer being compressed or stressed in the same way when we alter these things. Either way these tricks can be a powerful way to allow a sensitive shoulder to heal while continuing to train.

Changing Technique to Reduce Pain

In a typical powerlifting style of bench press the idea is to bring the shoulder blades back and down while bringing the chest up towards the bar. This technique extends the thoracic spine, locks the shoul- der blades into retraction and posterior tilt thus increasing subacromial space. This technique also shortens the range of motion the bar has to travel. Each of these factors may allow your athlete to press pain free.

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Distal Clavicle Osteolysis

Subacromial impingement syndrome isn’t the only commonly seen issue with shoulders. The other common issue with horizontal pressing (particularly bench press) is something called distal clavicle osteolysis.

Distal clavicle osteolysis commonly occurs in people who lift weights and is essentially irritation to
the AC joint which over times leads to degenerative damage. It is theorized that hyperabduction and extension of the shoulder under load places increased traction forces on the AC joint. The deeper into a dip and bench press the more the more extension we get and the more stress on the AC joint. These stresses are also worse with a wider grip. As the grip widens the degree of hyperabduction increases and with it the stress on the AC joint.

Over time this repetitive micro-trauma creates damage and resulting pain with disability. These patients generally present with pain right over top of the AC joint and pain when bringing their arm across their body. It usually wors- ens with pressing movements and can be worse the night following a day with a lot of pressing.

AC Joint – Source: wikimedia commons

Now, your job as a coach is not to diagnose the issue. It’s just important that you’re aware this may be going on. What’s important for this athlete is to avoid pressing that creates pain while the area calms down. Some easy modi cations we can try are:

1. Limiting Depth During Pressing and Dips

• This allows us to avoid as much traction force on the AC joint

Wide Grip Bench Press – Source: wikimedia commons

I personally see this issue in individuals who perform a lot of deep dips and bench press (particularly with the elbows aired out). It can either be something that occurs slowly over time or often times occurs with 1 rep gone wrong in a heavy dip or press.

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2. Board Press, Decline Press and Floor Press

• These variations also serve to decrease the amount of shoulder hyperextension/abduction, reduc- ing traction forces on the AC joint

3. Close Grip

• Close grip pressing decreases hyperabduction of the shoulder, limiting AC joint stress

4. Powerlifting Style Bench Press [Picture at vs power depth from side]
• Tucking the shoulders blades back and down while reaching the chest toward the bar generally

tucks the elbows closer to the body and limits the amount of extension at the shoulder when press- ing. These things decrease AC joint stress

5. Bands and Chains

• These variations place less stress on the shoulder at the bottom range of motion and more stress toward the top, decreasing AC joint stress

6. Change the Angle

• Sometimes increasing the angle pressing (incline bench press) is enough to stress the AC joint in a way different enough to eliminate pain

7. Switch to Pulling

• Pulling is normally well tolerated in these individuals and if pressing can’t be modi ed to eliminate pain then substituting rowing exercises for pulling works well.

Shoulder Pain and Horizontal Press Modi cation Key Notes

• Lack of rotator cuff control as well as shoulder position can create impingement in these folks
• Attempt to eliminate pain by modifying technique as described above, in some athletes this won’t

work so utilize the modi cation list below
• Pain can sometimes be eliminated by altering pressing angles, switching to dumbbells or other

different barbells
• Slow down reps or increase the rep number can eliminate pain while still allowing a training effect • In those with AC joint issues modifying the depth, grip, angle, technique or exercise variation can

often eliminate pain
• When all else fails, switch to a horizontal row variation

Shoulder Pain and Horizontal Press Modi cation list

Variations start from most challenging to least challenging. Attempt to use the most challenging exer- cise that can be performed without pain.

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1. For Barbell Bench Press

a. Barbell Bench Press → Slight Incline Barbell Bench Press → Slight Incline Dumbbell Bench Press → Flat Dumbbell Bench Press

2. For Pushups

a. Pushups → Inclined Pushup → Wall Pushup

3. For Ring Dips

a. Ring Dip → Parallel Bar / Between Boxes Dip → Pushup → Inclined Pushup

Shoulder Pain and Horizontal Press Health Work

These exercises can be added to someone’s training program when they are having pain when pressing horizontally

1. Band Pull-apart x 10
2. Biceps Curl x 10 reps
3. Reverse Flye x 10 reps
4. Pec Self Myofascial Release

**Perform 2-3 x per week in addition to regular pro- gramming

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Inclined Pushup

Horizontal Pressing and Wrist Pain

You’ll nd several people who complain of wrist pain with horizontal pressing. The same thing goes for overhead pressing and in particular handstand and crawl variations. What we believe is happening in these individuals is something called dorsal impaction syndrome.

In dorsal impaction syndrome the back side of the wrist is generally painful when extended and compressed. Think of the stress that goes through the wrist when holding a handstand. In dorsal impaction syndrome the structures on the back side of the wrist are getting compressed due to the unique stresses of bearing weight on an extended wrist (or extending the wrist while pressing a barbell).

As with every issue with pain in this product we recom- mend seeing a physician or licensed healthcare profes- sional before proceeding with your training. With wrist pain this is even more important because sometimes the pain in the wrist could be coming from a fracture. These fractures are very serious and need treatment right away.

Note the extended and compressed position

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