MODIFYING WORKOUTS FOR ATHLETES WITH PAIN

Vertical Pushing

• Shoulder • Low Back

Vertical Pressing and Shoulder Pain

Press, Push Press, Push Jerk, Split Jerk, Handstand Pushup, Snatch

Often times when someone has shoulder pain they also have pain with overhead pressing. I want to discuss a very common injury we see clinically and the functional anatomy. With this understanding the modi cations will make more sense when we discuss them.

Shoulder Impingement Syndrome (Subacromial Impingement Syndrome or SIS)

Shoulder impingement is the most common shoulder injury we see in the clinic. To understand what shoulder impingement is we rst have to understand the anatomy of the shoulder.

In the below picture we have the shoulder joint. Here are the key structures:

Source: wikimedia commons

1

14

1. The Humeral Head – This is the top portion of the bone in your upper arm. Normally it should stay snugly t centered into its socket, the glenoid fossa
2. Acromion, Coracoid and Coracoacromial ligament – These structures sit above the humeral head and between the ball and socket providing a small space aptly named the subacromial space.
3. Supraspinatus Tendon (part of the rotator cuff), long head of the biceps tendon and subacromial bursa – These structures sit between the humerus and the acromion in the subacromial space as seen above. These are the structures that get impinged upon with this syndrome.

Based on our knowledge of impingement syndrome several things can be occurring:

1. The rotator cuff and scapular musculature is not holding the humeral head rmly into the socket. Because of this the humeral head translates superiorly (goes up) and the contents of the subacro- mial space gets pinched against the acromion and humeral head. Part of the rotator cuff (supraspi- natus), biceps tendon and subacromial bursa are the victims of the impingement. These structures get irritated initially creating in ammation and resulting tendonitis. Over time this stress can create more long term issues such and tendinopathy and eventually rotator cuff tears.

Understanding Force Couples and Impingement

Something called a force couple helps to illuminate why overhead pressing can be painful in those with shoulder pain. With overhead pressing the deltoid muscles are heavily involved. Because of the location of the deltoid (Where it originates and inserts), the deltoid tends to pull the humeral head “up” or superior in the shoulder joint when we press overhead.

The job of the rotator cuff is to keep the humeral head centered in the socket. If the rotator cuff is dysfunctional or overpowered by the deltoid then you get the humeral head elevating and pinching (impinge- ment) on the rotator cuff. If the contents

of the subacromial space are irritated and sensitive we can have pain. Notice in the picture above you can see how the deltoid is imparting an upward force on the humer- al head whereas the rotator cuff pulls the humeral head tight into the socket. Too much deltoid without control from the rota- tor cuff and the humerus raises up pinching the rotator cuff, biceps and bursa against the acromion.

Note the direction of pull of the deltoid and how it would cause the humerus to translate superiorly

15

This is a vicious cycle. Weakness or dysfunction of the rotator cuff can create shoulder impingement. Impingement and pain can make the rotator cuff even more dysfunctional. When in pain the shoulder musculature generally doesn’t re appropriately. This potentially leads to more impingement and more dysfunction. The cycle continues until we do something about it.

Now you can see why the rotator cuff is so important with the health of the shoulder. If you have some- one with shoulder pain it stands to reason we have to be careful to eliminate shoulder pain during exer- cise so the rotator cuff can calm down and regain function.

Understanding the Painful Arc of Motion

The next important topic to understand is something called the painful arc of motion. In normal over- head elevation we naturally have decreased subacromial space as we bring our arms overhead. This is normal and natural. However, when the contents of the subacromial space are sensitive it can create pain in a predictable pattern. The reason for decreased subacromial space is due to the angle of pull from the deltoid. When the arm is below 90 degrees of motion the deltoid pulls the humerus superiorly (up) into the acromion. When the arm gets up past 90 degrees the deltoid now pulls the humeral head more into the socket, no longer pulling the humerus superiorly.

The painful arc displayed in the dumbbell press

The painful arc generally occurs in the range of 70 to 120 degrees of overhead motion. Keep in mind that this varies from person to person. However, people with impingement syndrome are generally most painful in the mid range of overhead motion and not at the top range.
It’s also the reason why pressing overhead can be painful but keeping a weight locked out at full ex- ion overhead may be well tolerated. These are the athletes that report that snatching is not painful but push press is very painful. This is because in a push press the shoulder is producing force through the painful arc where stress on the rotator cuff is at its highest. During a snatch the power to get the weight overhead is generated by the lower body. Your shoulder is essentially unloaded through the painful arc and then gets loaded again as we catch the weight fully overhead. This is an important implication be-

16

cause our athletes with painful shoulders may be able to perform movements like a snatch when they can’t perform pressing.

Overhead Press vs. Horizontal Press

In the overhead press you can clearly see that the shoulder goes all of the way through the painful arc of motion. In the bench press the shoulder more or less stays outside of the painful arc. Because of this, horizontal pressing variations like the bench press are often better tolerated than overhead press- ing in painful shoulders.

Picture of overhead press and arm angle vs. bench press with elbows tucked Painful arc vs. not

Also, in overhead pressing the pull of the deltoid is angled to pull the humeral head superiorly Check back to the above images on force couples for a refresher. In horizontal pressing the pull of the deltoid is more anterior (forward). This is because the anterior deltoid is so active during horizontal pressing and the orientation of those muscle bers will pull the humerus more forward than superior. For these reasons, some people with pain when pressing overhead can handle horizontal pressing without pain.

Just keep in mind that as we descend into the bottom of a dip, pushup or bench press the shoulder moves into extension. Based on our understandings of joint arthrokinematics we also know that exten- sion of the shoulder will drive the humerus forward. Without adequate control from the rotator cuff the structures in the front of the shoulder get compressed.

Either way, both forms of pressing will stress the shoulder in a different way and we can use this infor- mation to help our athletes press without pain.

17

Why Jerks are Often Times Painless

The push jerk and split jerk is an interesting beast because sometimes we can get away with perform- ing this pain free as long as we don’t have to lower each rep back down to our front rack. Why is this? Let’s go back to the snatch example. When we snatch we don’t load the shoulder through the painful arc. The power is generated through the legs and we catch the weight fully locked out. The same is happening in the push jerk. The power is generated for the lift through the lower body and then the weight is caught with the shoulders and elbows fully locked out. Because of this we aren’t loading the shoulder joint heavily throughout the painful arc. This is good news for us because sometimes our ath- letes with painful shoulders can jerk pain free if they drop each rep from overhead or utilize jerk blocks.

Rotator Cuff Strength and Fatigue

Obviously after reading the last section it should become apparent that the rotator cuff is extremely important. The goal is to ensure that the rotator cuff is strong enough to handle all of the overhead work we throw at it in the gym. The other important variable is rotator cuff endurance. If the rotator cuff fatigues during overhead work then it stands to reason that we may be creating some impingement as the rotator cuff is no longer able to control motion in the shoulder joint. Many people don’t start having shoulder pain until halfway through a tough set or shoulder intensive session.

For the athlete that is coming back from a shoulder injury we need to keep these things in mind when designing a training program. If we throw a met-con at them with a lot of overhead pressing we may run into issues because the cuff is not as robust as we’d like it just yet. We need to slowly ramp up volume for these athletes. This can be as easy as decreasing total repetitions in a given met-con or breaking up your sets (especially if pain kicks in).

Shoulder Pain and Overhead Press Modi cation Key Notes

• Overhead press is generally one of the toughest things to perform when painful. It often needs to be taken out of the program temporarily for painful shoulders
• If you can’t nd a pain free press variation, rowing variations are generally well tolerated and serve as a good modi cation. You’ll learn more about why overhead pulling is generally less painful in the vertical pulling section.
• Pressing in a more horizontal plane (bench press) may be better tolerated than overhead press.
• Reducing the load, slowing down the speed of the lift and increasing the reps can sometimes allowus to still get a training effect and eliminate pain.

18

Shoulder Pain Overhead 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.

1. For Split Jerks

a. Barbell Jerk → Jerk off Blocks → Snatch → 1 arm snatch → oly variant (Clean/snatch pull)

2. For Push Press / Press

a. Barbell Push Press → Dumbbell Push Press → Barbell Press → Dumbbell Press → Horizontal Pushes → Horizontal Pulls

3. Handstand Pushup

a. Handstand Pushup → Pike Handstand Push Up Feet Elevated → Pike Handstand Push Up → Knees on Box Handstand Push Up → Push Up → Horizontal Pull

Pike on box vs. Pike on oor vs. Knees on box

Accessory Shoulder Health Work

These exercises can be added to someone’s training program when they are having pain when press- ing overhead.

1. Foam roll lats and teres major x 10 passes
2. Thoracic spine foam rolling x 10 reps
3. Ring rows 3 x 8-12 reps
4. Side lying external rotation 3 x 8-12 reps
5. Scaption / front raise 3 x 8-12 reps

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

19

2

Vertical Pressing and Lower Back Pain

Press, Push Press, Push Jerk, Split Jerk, Handstand Pushup

Lower back (lumbar spine) pain is common with overhead pressing. Generally this occurs in individuals who like to extend too much and too frequently in their lumbar spine when performing overhead press.

What we’re interested in are the elements toward the back or “posterior” elements of the spine. In the back of the spine we have a lot going on. Structures back there include:

• Muscles and Tendons • Ligaments
• Facet Joints
• Boney Structures

When we extend the spine, the posterior elements are compressed which can increase stress on these struc- tures. If we perform enough repetitive extension we can end up in pain. Where I think we end up in trouble with overhead press is that we’re combining extension with compression (due to the weight we’re pressing over- head) which is a double whammy to these posterior elements.

Athletes who utilize a lot of extension of the lumbar spine during overhead activities are more at risk for something called spondylolysis and spondylolisthesis. Spondylolysis is a fracture of one of the posterior ele- ments of the vertebrae. Spondylolisthesis is a fracture along with slippage of one vertebrae on the other.

These injuries are common in sports like gymnastics although anecdotally I’ve seen them occur in overhead pressing athletes. I’ve personally seen them occur in strongman athletes while performing log press. Log press requires quite a bit of lumbar extension and if you do it frequently enough, heavy enough and with poor enough technique it can damage your spine. This person in particular ended up going through surgery to correct the issue.

Being stiff in certain areas can also increase the stress on the posterior spine. These areas are the thoracic spine (limited extension), hip exors (limited extension) and lumbar spine (limited exion).

20

Fortunately for us, we can minimize lumbar extension during overhead pressing. Before we discuss how, let’s discuss why it occurs. Excessive lumbar extension during overhead press can happen for a variety of reasons:

• Limited Overhead Mobility

◦ Limited overhead mobility from the shoulder or thoracic spine will force lumbar spine extension as a compensation to get the weight overhead.

• Anterior Pelvic Tilt

◦ Tightness in the front of the hip and lumbar spine coupled with weakness of the core, ham- strings and glutes can lend to this position. Anterior pelvic tilt creates additional lumbar exten- sion, which we’re trying to combat.

Note the belt pointing down and increased lumbar curve

• Strength and Motor Control Issues

◦ Poor technique
■ Sometimes we just don’t have the best coaching

available to teach us how to keep our spine in a

neutral position when pressing overhead
◦ Your body’s attempt to nd the strongest pressing

position
■ Extending at the lumbar spine and leaning back

before pressing allows our body to utilize bigger and stronger pressing muscles like the pecs. This increased extension may allow for more weight pressed overhead but potentially at the expense of your lower back health

◦ Too much load
■ This goes hand in hand with the above point. If

we have too much load we’ll hyperextend at the lumbar spine to utilize stronger pressing muscles. Hyperextending the lumbar spine also can create some stability in the lumbar spine by compressing these posterior elements. Unfortunately com- pressing these posterior elements is not a healthy compensation.

As a coach we can often easily modify someone’s technique and often times quickly eliminate some- one’s pain. This also means that as a coach we can prevent extension based low back pain if we know to avoid these hyperextended positions.

21

Press

Jerk

Excessive lumbar curve vs. neutral

Excessive lumbar curve vs. neutral

22

Split Jerk

Handstand Pushup

Excessive lumbar curve vs. neutral

Excessive lumbar curve vs. neutral

23

Lower Back Pain and Overhead Press Modi cation Key Notes

• Attempt to eliminate pain by modifying technique, in some athletes this won’t work so utilize the modi cation list below
• Some athletes won’t be able to be coached into good positions simply due to tightness. If an athlete can’t correct movement with cues and the load is manageable you can begin thinking they may have mobility restrictions
• If you believe an athlete is overextending due to excessive weight, lower the load. These athletes generally have ne technique at lower loads and then the form worsens as the load increases.Lower Back Pain and Overhead 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.

1. For Split Jerks

a. Split Jerk → Power Jerk → Push Press → Push Press Regression

2. For Push Press / Press

a. Barbell Push Press → Press → 1⁄2 Kneeling Dumbbell or Barbell press → Seated Military Press → Incline Press

3. Handstand Pushup

a. Handstand Pushup → Pike Handstand Push Up

1⁄2 Kneeling Dumbbell Press Piked Handstand Pushup

24