SHOULDER INJURIES

As a trade-off for mobility, the shoulder lacks some of the stability found in other joints.The shoulder is under considerable stress during many commonly performed weight training exercises and, as a result, is frequently injured. Shoulder pain is often taken for granted or ignored by many bodybuilders. For example, anterior shoulder pain felt secondary to performing bench presses (ie, achieving a "burn") is frequently assumed to be a sore anterior deltoid muscle from a hard workout. It may, in fact, represent a sign of rotator cuff strain or impingement.

Impingement syndrome and anterior instability are the most common types of shoulder conditions associated with weight training. It is important to recognize that these conditions often coexist. Rotator cuff strain/tendinitis/tear, proximal biceps tendinitis, and subacromial bursitis frequently result from subacromial impingement. However, primary tendinitis resulting from overload may also occur. Less common types of shoulder injuries include brachial plexus neuropathy, suprascapular nerve impingement, posterior glenohumeral instability (due to heavy bench presses), acromio-clavicular joint sprains (AC), proximal biceps tendon tears, pectoralis major strains or tears, and osteolysis of the distal clavicle.



Impingement syndrome

Impingement syndrome refers to impingement of the rotator cuff tendons, especially the supraspinatus tendon, under the subacromial arch. The biceps tendon or the subacromial bursa may also be impinged under the subacromial arch. The position that appears to be most damaging is abduction with internal rotation. It is not clear whether rotator cuff muscle/ tendon overload precedes impingement or is caused by it.

A major factor in shoulder impingement injuries in weight lifters is the muscle imbalance syndrome mentioned earlier, highlighted by overly tight shoulder internal rotators and weak shoulder external rotators. A substantial portion of the typical training program is dedicated to training the pectorals and the lats. Both tend to produce internal rotation of the shoulders. The external shoulder rotators (the infraspinatus and the teres minor) are often neglected.

There is considerable stress imposed on the rotator cuff muscles during the performance of many exercises, such as the bench press. Too many sets of exercises for the same body part with excessive weight can result in fatigue and overload injury to the rotator cuff. Therefore, weight lifters should be encouraged to perform fewer sets and no more than 12 sets per body part, including warm-ups.

A common exercise is the lateral raise with the shoulder in internal rotation. The lifter is often instructed to point the thumb down as though pouring water from a pitcher in an effort to better isolate the side deltoid. It may be true, but there is a risk of accelerating or aggravating an impingement syndrome. The clinician should suggest that lateral raises be performed face down on an incline bench positioned at about 75 degrees up from the ground. This position will isolate the side delts without creating impingement.

Another common mistake is raising the arms above 90 degrees while performing side raises. Unless the thumb is pointing up, this position may increase the risk of impinging the rotator cuff tendons under the subacromial arch. Shoulder protraction is associated with narrowing of the subacromial space. Allowing the shoulders to become protracted forward beyond the neutral position during the performance of exercises such as bench presses may increase the strain to this area.



Anterior instability of the glenohumeral joint:
Instability may be due to a single-event trauma where the capsule and glenoid labrum are torn or may be atraumatic representing a tendency toward a loose joint capsule. When either inherently loose or torn loose, the capsule may be unable to support the shoulder in the extremes of abduction and external rotation. Therefore, exercises that place the shoulder in this position should be modified or avoided such as the behind-the-neck press, the behind-the-neck pulldown, and the pec deck. It may also occur from repeatedly hyperextending the shoulder during the performance of bench presses, flyes, and the pec deck by lowering the bar or dumbbells to the point where the elbows are behind the back. Weight lifters not only place their shoulders in an abducted/externally rotated or hyperextended position, but also do it with considerable weight held in their hands. The general principle to use in advising patients is to avoid positions in which the elbows extend behind the coronal plane of the body. It is important to remind the patient that overhead positions are less stable and therefore more risky. While instability is often caused by gradual repetitive capsular stretching injury, Olympic lifters tend to suffer instability resulting from a single-event traumatic injury. They often lose control of a weight while holding the weight in an overhead position.




It should be noted that the diagnosis of anterior instability may be overlooked due to a misleading response to testing. Patients often experience pain in the posterior shoulder when the arm is placed in an abducted/externally rotated position. It is thought that this posterior pain arises from traction or compression of the posterior structures as the shoulder subluxates forward. Also, anterior instability may be misdiagnosed as a rotator cuff strain.

The load and shift test is a form of instability testing that involves passively translating the humeral head while stabilizing the glenoid. This test may be performed with the patient in various positions, including seated with arm by the side, seated with the arm in the abducted and externally rotated position, and supine with the arm abducted and externally rotated. Excessive forward excursion of the humerus associated with either pain, apprehension, or clicking may all be considered positive signs. The relocation test should reduce the positive findings. This test involves restabilizing the humerus by pushing the head of the humerus from anterior to posterior while placing the arm in the "apprehension" position of abduction/external rotation. The relocation test is performed with the patient supine. Care should be taken to support the arm to avoid protective muscle spasm.(53)

Impingement may occur secondary to shoulder instability.(60) The response to testing includes pain felt with the apprehension test that is relieved by the relocation test. Apprehension is usually not the primary response to testing. In such cases, the underlying instability and the subsequent impingement should both be addressed.




Less common shoulder injuries related to weight training:

There have been a number of reports in the literature of suprascapular nerve injury either via stretch or compression. Abduction of the arm against resistance has been implicated as the mechanism of injury.The lateral raise and the shoulder press are two exercises that involve abduction against resistance.



A number of reports document the occurrence of tears of the pectoralis major muscle or tendon, usually from bench pressing. The tendon may either avulse from the bone, tear at the musculotendinous junction, or tear in the muscle itself, usually near the musculotendinous junction. Most of these injuries occur while the arms are extended behind the chest.(20) To prevent such injuries the lifter should avoid lowering the bar to the point at which the shoulder is hyperextended.Regular stretching may be helpful.



An entity known as atraumatic osteolysis of the distal clavicle has been reported in a number of studies as being related to weight training. This condition, referred to as weight lifter's shoulder, is marked by pain at the acromioclavicular joint while performing the dip, bench press, clean-and-jerk, and overhead presses. Radiographs show osteoporosis and loss of subchondral bony detail at the distal clavicle. In addition, cystic changes may also be present.Atraumatic osteolysis is believed to result from repetitive loading of the acromioclavicular joint resulting in neurovascular compromise to the distal clavicle. Management is difficult given that most patients are serious lifters. Either a dramatic reduction in weight, elimination of the offending maneuver, or substitution of exercises may be suggested. Alternatives to the bench press include a narrow grip bench, cable crossovers, and the incline or decline press. If unsuccessful, elimination of heavy lifting for 6 months is recommended. There is some evidence that those treated surgically with amputation of the distal I to 2 cm of the clavicle are able to return to some lifting. However, many athletes are not able to return to a pre-injury level of lifting.






Recommendations for Preventing Shoulder Injuries While Weight Training

1. Do not ignore shoulder pain. Training through the pain will only lead to further and more severe injury.

2. Avoid exercises where the arm is abducted (raised to the side) in an internally rotated position, such as upright rows and thumbs-pointed-down laterals. Also, do not raise the arms above 90' while performing lateral raises.

3. Strengthen the external rotator muscles of the shoulder and keep them strong. This process involves regularly performing rotator cuff strengthening exercises-not just when you have an injury. The strength of the rotator cuff muscles should keep pace with the strength of the pectoral and deltoid muscles.

4. Keep the internal shoulder rotators flexible to avoid shortening. Be careful to avoid instability. Forceful stretching and stretching with weights should be avoided.

5. Avoid exercises where the rotator cuff is under extreme load.

6. Warm up the shoulders carefully before exercising them.

7. Strengthen the middle and lower traps and rhomboids to increase shoulder stability and ensure better scapular stabilization. Avoid protracted shoulder postural problems.

8. Avoid the pullover exercise or use with extreme caution. Care should be taken not to extend the arms back too far.