MODIFYING WORKOUTS FOR ATHLETES WITH PAIN

Vertical Pulling

• Shoulder

In vertical pulling the movement where we see issues with pain is generally during kipping. During vertical pulling exercises we run into trouble with technique, positional problems as well as strength and endurance issues as we discussed earlier with shoulder pain. First let’s discuss some speci cs about vertical pulling so we can best modify for and help athletes with pain during these movements.

Why Does Overhead Press Hurt But Pullups Don’t Hurt?

In our athletes with subacromial impingement syndrome generally overhead pulling (like a strict pullup) is much less painful in comparison to overhead pressing. This goes back to the explanation of force couples we went over in the vertical pressing and shoulder pain section. In overhead press, the deltoid pulls the humeral head superiorly, potentially creating some pain at the shoulder when the contents of the subacromial space are sensitive. When performing overhead pulling exercises (like pull-ups) the deltoid is relatively inactive whereas the musculature that depresses the humeral head (like the lats) are very active.

In overhead pressing the deltoid is pulling the humerus upwards and with a lack of rotator cuff force coupling we get impinge- ment. In overhead pulling the deltoid is not pulling the humer- al head up but the opposite is occurring. The lats are pulling the humeral head down away from the acromion decreasing compression on the rotator cuff. This is great because generally painful shoulders tolerate rowing and pulling well when they don’t tolerate pressing.

Note the lats pulling the humerus down away from the acromion

Positional Impingement of the Shoulder

Just as in the dip, certain positions of the shoulder blade and shoulder will create more stress on the shoulder. These positions create impingement not just from a lack of rotator cuff control but from com- pression of the subacromial contents 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.

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Impingement from tight lats

Tightness in the internal rotators of the shoulder, particular the Latissimus Dorsi (aka the Lats) and Teres Major will cause compensation when we perform vertical pulling exercises like a kip (toes to bar, pull-up etc.)

To better explain this concept let’s further explore the Lats:

• The lats attach from the humerus (upper arm bone), down to the thoracolumbar fascia, which inserts direct- ly into the pelvis. You can see this in the picture of the lats in red.
• The lats function to extend and internally rotate the arm as well as to extend the lumbar spine. They are very active during vertical pulling.
• When restricted, the lats have the potential to limit shoulder exion (bringing the arms overhead), exter- nal rotation (rotating the thumb back) and lumbar ex- ion. The restrictions we see at the shoulder are what is most important for shoulder health.If you have an athlete with restricted overhead motion because of tight lats then when you try to force overhead mobility you’ll create compensation. Think of it this way. Let’s take an athlete with restricted overhead mobility due to lat shortness and have them perform a kipping motion. Where you’ll see the compensation is during the backswing or arch portion of the kip, where maximal shoulder exion is required. Compensation can be seen in several ways:

1. The hands get much wider (on rings)
2. The elbows will bend
3. The lumbar spine will arch excessively
4. The backswing will be limited in motion
5. The shoulder will internally rotate

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Shoulder Health Side Note

The Pecs are also internal rotators of the shoulder. Having tight pecs can also cause shoulder compen- sation when performing overhead motions. This is more common in overhead movements that require a wide grip like a snatch. This is simply due to the anatomy of the pecs and that they restrict overhead motion more with a wider grip then narrow grip. During narrow grip movements (like jerks, handstands and kipping) the lats and teres major are usually more at fault whereas in the wide grip movements (snatch, overhead squat) the pecs probably play a larger role.

In orthopedic medicine there is a test for subacromial impingement syndrome. It’s called the Neer’s test. In the Neer’s test the patient’s shoulder blade is stabilized, the shoulder is internally rotated and then shoulder is then fully elevated. The test is designed to bring the greater tuberosity into contact with the acromion of the shoulder. The rotator cuff, bursa and long head of the biceps gets compressed or impinged with this test. The thought is that if there is damage or sensitivity in those structures, you’d get a positive test (pain).

In a situation where the lats are stiff and we’re forcing our athletes into full exion like in the kipping example above, the shoulders will internally rotate once we reach the end limit of our exion. Now the shoulder is in full exion and internal rotation, just as in the Neer’s test. Remember that the Neer’s test was designed to recreate impingement of the shoulder as a test for impingement syndrome. We may be creating impingement syndrome by forcing our athletes into these positions.

This means that the rotator cuff is getting impinged upon with each pull-up, toes to bar or muscle-up. This may not hurt on the rst reps or the 100th but over time these athletes can develop painful shoul- ders. Once they’re in pain we need to understand these mechanics so we can learn how to modify appropriately.

For these athletes it’s important that we strive to improve their range of motion and also not to force a big backswing during their kip. Often times with these athletes, shortening the backswing and tightening the kip can eliminate shoulder pain.

Video of tightening kip swing for shoulder pain modi cation

We also want to focus on gaining as much range of motion with these athletes from their thoracic spine (upper back). If extra motion at the shoulder is creating problems it makes sense that getting it from another joint can be helpful.

How the Shoulder Blade Affects Rotator Cuff Health During Kipping

The other variable that’s important with overhead motion is what we do with our shoulder blade. As we bring our arms overhead the shoulder blade is meant to upwardly rotate and posteriorly tilt.
Both of these motions increase subacromial space. If we block upward rotation by “packing the shoul- der blade down” we’re actually bringing the acromion closer to the humeral head and creating impinge- ment. This is important because shoulder packing is a popular term and often utilized when it shouldn’t be for shoulder health.

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So how do we teach proper overhead motion? First we need to clear up any mobility restrictions. If we’re limited with overhead mobility then we won’t be able to achieve proper positioning overhead, plain and simple.

Once mobility is cleaned up or after mobilizing we want to reinforce better motion at the shoulder blade. I’m a fan of the reach, roll and lift drills to accomplish proper shoulder blade positioning. Here’s what we accomplish with this tool:

1. Reach – Promotes upward rotation of the scapula, clearing space between the humerus and the acromion

• [Pics upward vs downward]
2. Roll – Promotes external rotation of the shoulder clearing space between the greater tuberosity and

the acromion
• [Pics IR vs ER]
3. Lift – Promotes posterior tilt of the scapula further increasing subacromial space • [Pic from side]

For a video demonstration of how to accomplish this while hanging click HERE

Shoulder Health Side Note

The position of the shoulder blade is directly affected by the ribs and thoracic spine. A exed or round- ed thoracic spine will contour the ribcage in a way that promotes anterior tilt of the scapula. We’re look- ing for posterior tilt of the scapula for increased subacromial space and subsequent shoulder health. This is why thoracic spine extension mobility is so vital for healthy shoulders.

After this explanation hopefully it becomes apparent of the need to properly teach overhead positioning for your athletes. This progression is also something that can potentially eliminate shoulder pain in the athletes you are currently dealing with who have pain while kipping.

The other area where athletes run into trouble in the shoulder during vertical pulling is when they lack control in the joint. The rotator cuff and humeral depressors (lats) keep the ball of the shoulder centered in the socket during vertical pulling. If these structures are not strong enough or if they fatigue they may not control motion in the shoulder joint well.

If we lose control in the bottom of a pull-up the humeral head is free to migrate up and cause forceful impingement of the rotator cuff. This is the same mechanism as in the Neer’s test described earlier. Without control from our musculature we’re also relying more heavily on the passive structures of the shoulder to control motion in the shoulder joint.

The culprit movements for this mechanism of injury are usually higher repetition kipping pullups. During a kipping pull-up the momentum to complete a repetition occurs at the bottom of the pull-up. Power
is generated there in order to get the chin or chest to the bar and then gravity pulls us back down to the starting position. As we fatigued the descent becomes harder and harder to control due to fatigue. Meanwhile we can usually squeeze a few more reps in because we’re generating momentum from a kip. We just don’t have the endurance left to control the descent of the pullup well.

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If your athletes are moving quickly through a higher rep set with minimal to no rest between sets they aren’t allowing adequate time for muscular recovery and the shoulder is stressed more and more with each repetition. We can combat this by picking rep ranges that are appropriate for the athlete in front of us. We can also combat this by building strength and stability in the bottom position of our pullups.

Video of scap stability video bottom of pullups

The next problem is that many people simply don’t have the strength to perform a pull-up. Obviously those without adequate strength should be working on their ability to perform a few pullups before going to kipping.

The problem with using a kipping pullup variation that is too challenging for people is that they end up losing their hollow / arch timing due to lack of strength. What we end up seeing is an athlete struggling to get their chin over the bar. Inevitably they don’t pull high enough, aren’t able to push away at the top of the pull-up and can’t get back into a hollow position before hitting the bottom of the pullup. At this point they don’t have the momentum to create another arch position and they lose their kip.

Also, this lack of pushing away at the top of the pullup leads to hitting harder at the bottom of the pull- up. This increases the stress on the shoulder and diminishes the ability to link reps together. You can see a video of Dan demonstrating this in the lecture portion of vertical pulling.

A better way to progress athletes is not to focus on getting the chin over the bar but instead nding a happy intermediate by not pulling as high and being able to push away at the top of each rep. This will allow athletes to learn the timing better and allow them to focus more on hollow and arch positions (in a safer way)

C-kip Progression Video

The same can be used for learning how to butter y with athletes. If they don’t have the strength they can still work on the timing and positions.

Butter y Kip Progression

Shoulder Pain and Vertical Pull Modi cation Key Notes

• Lack of rotator cuff and scapular control can create impingement and reliance on passive structures in the bottom of a pullup
• Decrease repetitions or utilize an easier kip variation for these folks
• Focus on strict strength
• Lacking mobility of the shoulder internal rotators can create impingement in the back swing (arch)portion of kips
• Improve shoulder and thoracic spine mobility
• Switch to a more horizontal row variation to avoid impingement at the bottom of a pullup

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