Since I started writing for Swimming World and Swimmer Magazines I receive many e-mails and questions about shoulder pain. These questions range from common sense to abstract questions, but have forced me to study and research everything about the shoulder. Many people feel the shoulder is a complex joint, but I’m here to tell you it is simpler than you think.
Luckily (I think), I’ve been able to work with many swimmers. My involvement has included prevention and rehabilitation. Of all the body parts, shoulder prevention is mandatory for overhead athletes and those frequently using their arms. I want to discuss some misconceptions about the shoulder. These are common questions or comments I often hear. Don’t let these confusions prevent you from building the strongest shoulder necessary for a pain-free life and career.
#1 Pain Referral is Erratic
I’ll never forget when a Master’s coach I worked with told me he didn’t believe in shoulder prevention because shoulder pain is going to happen and has a random referral, so why treat something we don’t know anything about? This was the first statement that motivated me about swimmer’s shoulders. I remember having a lively debate with this coach and I made several points that the shoulder has very common referral patterns (read here) which are prevented with proper tools. Unfortunately, this coach had a predetermined mindset from bad past experiences. Luckily, his swimmers were not. I ended up treating and preventing a lot of shoulder pain with this Master’s team and thank them for being some of my earliest guinea pigs (note I didn’t say my last guinea pigs…). A simple rule of thumb, the infraspinatus (outside rotator cuff muscle) refers to the outer aspect of the shoulder. The subscapularis refers to the top of the shoulder and the biceps refers to deep within the joint and down the front of the arm. There are many other referrals, but these are the most common with overhead athletes. Remember, just because you feel it on the side of your arm, doesn’t mean it is the source…I rarely treat the deltoid!
#2 Rotator Cuff Muscles are all that Matter
I swam for a small team growing up. I loved this team and organization for making me a successful swimmer and lifelong advocate of the sport. Unfortunately, this club knew nothing about strength and conditioning or shoulder prevention. My coach tried his best to study the subject, but his college math degree did little for sports performance. To prevent shoulder pain our team did internal and external rotations until the cows came home!
Now, the rotator cuff is important and internal and external rotation are necessary, but it essential to perform these exercises properly. A lot of people use out-dated exercises, which actually stress the structures they are trying to protect. Thumbs down shoulder raises to strengthen the supraspinatus are causing more injuries than preventing!
This thought process is almost the exact opposite of the Master’s coach I worked with. These coaches usually blame the rotator cuff for everything and use the logic, if the rotator cuff is hurt, we must fix the rotator cuff! Unfortunately, it isn’t that simple. Most of the rotator cuff muscles need improved strength, but more importantly need improved muscle length and timing. The upward rotators and scapular stabilizers are more important structures to strengthen as they move the shoulder blade and build a strong foundation for excessive mobility and movement seen in many shoulder injuries in overhead athletes.
Lastly, don’t just look at the shoulder. The thoracic spine and sometimes cervical spine play a major role in shoulder pain. I cannot count all the times I’ve seen someone with shoulder pain and only worked on their mid back. The thoracic spine is sometimes the key to shoulder health, don’t neglect this vital part.
Oh yeah, the hips can also play a role in shoulder pain, especially in pitchers and athletes pivoting during their overhead movement. In my experience, this is less likely a cause compared to the mid back, but if all else has failed consider the hips. Remember, the hips don’t lie!
#3 No Pain no gain!
Many have heard from coaches or gym teachers, no pain no gain! Unfortunately, this is more harmful than good in the shoulder. A lot of athletes can not differentiate soreness and injury. Shoulder pain from injury is a big difference and must be identified earlier rather than later. Unfortunately, some pain is unavoidable due to anatomy. There is a select population that has a type III, hooked acromion which will rub their rotator cuff during all overhead movements. The only way to “fix” this acromion is surgery.
The facts are, each body is not created equal, a hard but essential fact to accept. Moreover, each body is not equal over time. If you use your shoulder a lot, it is likely you are going to have irritation and rubbing inside the shoulder joint. This can lead to calcium deposits resulting in a type III acromion. Also, if you have a desk job and sit for 20 hours a day, it is likely your body is undergoing a kyphotic position. This can greatly impede shoulder function, as we know how much the mid back influences shoulder pain! Next time you are in the gym or practice and your shoulder hurts the transition to an activity that does not irritate your shoulder. In the weight room there is always something you can do. Even in the pool, it is easy to transition to a different activity, try kicking on your back instead of keeping your shoulder in constant shoulder over pressure on the kickboard!
#4 Shoulder Stretching is Mandatory
I’m not saying no one needs to stretch their shoulders. But I am saying many overhead athletes already have too much shoulder range of motion and need more stabilization than mobilization. Often time’s coaches use the theory of association to train. They see elite athletes with a lot of range of motion and think if some range of motion is good, than more must be better. Unfortunately, this can put the risk for instability.
#5 Poor Posture Causes All Shoulder Pain
Physical therapy school beat this concept in my head. Unfortunately, it is simply a myth. Look all around you, everyone has bad posture! The only person who has good posture is biomechanics man. This mythical superhero exists on a planet far away, no where I’ve ever seen.
I remember in my PT classes watching everyone sit in slumped; head forward postures, then we’d go up and down and ridicule each other’s postures. This is hypocritical and out of control. Sure, stagnant poor posture for a repeated time can put one at risk for shoulder injury, but it isn’t the cause. I was recently quoted in Swimmer Magazine and instructed getting up every hour to prevent stagnant poor posture. Everyone is going to sit with poor posture, the key is to get up and move around frequently to break the cycle. I questioned the postural analysis back in school when I watched a tenured therapist scrutinize a patient’s posture from head to toe. This therapist went on a rant about a classmates shoulder pain, stating the cause was from their subtalarjoint (don’t worry about what it is, just know it is in the foot) being out-of-place! This misplaced precision and analysis brings down the moral of a patient and is likely a long shot. Why not go to someone who is going to help build you up, then shake their finger at you if you slump and if your big toe is out of whack! Give your body the tools to have bad posture from time to time, then get up frequently with an active lifestyle, trust me this is realistic and beneficial.
#6 Bench Press and Push-ups are Dangerous
This rumor is mildly true due to poor programming and biomechanics. However, if dosed properly and with correct biomechanics, the bench press and push-up are actually beneficial for shoulder health. I wouldn’t put them in my top five shoulder prevention or rehabilitation exercises, but for high level athletes, these exercises are essential and hard to avoid (since strength and conditioning specialist and coaches love these movements), read my article on bench-press part I here. I recommend reading these articles, but in short, keep the shoulder blades stable and secure!
#7 Overhead press and Delt Raises are Good
I am not an advocate of overhead presses in any of my overhead athletes. I never was a fan of these movements and my opinion solidified after watching Eric Cressey and Mike Reinold discuss the subject. These experts in the field never allow their athletes to overhead press. Why increase the use of these joints and muscles when it is likely they are already highly stressed and impaired? It is essential to protect these joints and maximize performance on the field. Unfortunately, many coaches stress these muscles over and over, fatiguing them and putting them at risk for injury. Give them a rest; allow them to work properly on the field/pool/arena/grass!
#8 Breathing is Irrelevant!
I did a three-part series on Swimming Science about breathing and its role with shoulder health and fatigue. It is important to confirm the athlete has proper breathing patterns and they aren’t over stressing their shoulder muscles (secondary breathing muscles). If they are overusing these muscles, they will fatigue and potentially increase one’s risk for injury and impair performance. Think about it, if you are using your lats, pecs and upper back to breath (cheater muscles), they will be fatigued during a race and increase your risk for injury and put you at risk for injury, double whammy!
These are some of the the most common 8 shoulder squabbles at the shoulder joint. Don’t fall to the myths and misconceptions, get the facts straight and start using them correctly today! Next, week I’ll discuss more shoulder squabbles, stay tuned!