GENERAL GUIDELINES FOR TRAINING WITH ANY INJURY
- Refer out!
We are strength coaches and personal trainers, NOT doctors. We do not make medical diagnoses. Anything that is painful, please refer out to a doctor or specialist in your area. Do your best to make this person a part of your network as it's about helping the individual, not about egos. In the end, everybody should win: you, the doctor, the therapist, and most importantly the client/athlete.
- Ask them: Does it hurt?
Only a yes or no answer will suffice. “Kind of,” “not really,” and “only when I…” are a yes. Refer out, and then regress or eliminate any exercise that causes pain. Read Coach Boyle's “Does it hurt?” article for more information.
- Use an assessment.
At MBSC, we use systems from Functional Movement Screen like the FMS and SFMA. We find these to be the best systems currently available to look at gross movement quality and identify entry points for improvement in training.
When using the FMS, specifically for pain-free clients, the simplified scoring system allows our coaches to put clients into buckets based on their movement quality. Scores of 2 or 3, don't raise any red flags meaning they can continue training the associated pattern normally. A score of 1, would signify a limitation in gross movement quality, warranting a regression to an simpler movement and further investigation into local joint movement quality. A score of 0 means there is pain associated with the movement, meaning we refer the client to a medical professional for treatment and continue to train the non-painful patterns. Generally speaking, non-specific back pain clients could use more mobility in their hips and thoracic spine and improved motor control of their hips and core musculature.
If you are not familiar with the Functional Movement Screen, you can employ the “Does it hurt?” method above and set up your programming from there. *Note: There are always exceptions to the rule. Think young pliable athletes and yogis. Usually, they're a case for getting stronger, not more mobile!
- Manage your expectations.
Training age, chronological age, previous injuries, joint replacements, and surgeries are all variables that could negatively effect training outcomes, although they're not an excuses for in-action. Braces, sleeves, ice, heat, taping, compression, NSAIDs, and passive care are just band-aids. Their purpose is to minimize inflammation, stabilize the injury, and help the healing process. Once a cut (injury) heals, you wouldn't keep wearing a band aid (modalities & passive care) would you? These modalities are meant to be used sparingly, not relied on.
- There is always something…
we can be doing while an injury heals. If your right arm is broken, you have three other limbs and a core to train. The positive systemic benefits of exercise on the human body will aid in the rehabilitation of (X) body part or segment even if you are not training it directly. Movement is Medicine.
There's a reason it's “tight”. Be sure you're stretching or mobilizing the correct thing and that you backup all of your work with proper stability & strength work. This is especially important when dealing with a delicate shoulder joint and is usually best left up to the PT or doctor. Do NOT blindly stretch (especially when using distraction work with bands). You could be lengthening or loosening the only thing holding the (enter joint here) together and make it worse. Proceed with caution and know your role as a strength coach or personal trainer.
CONTRAINDICATED EXERCISES FOR CLIENTS WITH SHOULDER PAIN
1. Heavy Overhead Pressing and Rowing
- Barbell/ Kettlebell/ Dumbbell Press
- Chin ups/Pull-ups
- Overhead Carries
- Overhead Squats
2. Explosive Upper Body Plyometrics
- Overhead Medicine Ball Throws
- Plyo Push Ups
- Barbell/ Dumbbell/ Kettlebell Snatches
3. Heavy or Difficult Horizontal Pressing and Rowing – where the hands & shoulders are not able to rotate naturally
- Bench Press
- Barbell Row
- Push Ups
4. Core Work that involves the shoulders
- Heavy Turkish Get Up's
- Plank Rows
- Side Plank
- Front Plank, the Push Up Position or the Bear Crawl position, can be too much compression on the shoulder joint for some
5. Conditioning Work Involving the Shoulder
- Sprinting due to dynamic arm action involved
- Battling Ropes – due to the sometimes erratic motion of the arms or implement
- Rower or Ski Erg
- Stay away from most Met-con work. It leads to serious fatigue where the client is usually trying to beat the clock and focusing on quantity not quality.
THINGS TO TROUBLESHOOT WITH CLIENTS WHO HAVE SHOULDER PAIN
Note the word “troubleshoot” here. Anything below could be contraindicated depending on the individual. We have found through our experience that the information provided below has worked well for our shoulder pain clients. Please consult with a good physical therapist, chiropractor, or doctor who understands the importance of quality movement to get a second opinion on your programming. We see this as “best practice” for any injury: everyone working together for the sole purpose of getting the client healthy.
Upper Body Plyometric Work
- Medicine Ball Side Toss
- Light Chest pass & Shot puts are generally OK
- Bent Elbow Medball Slams are a good way to limit the range of motion to work your way back to Medicine Ball Throwing overhead
- Light Cleans – beware that the “catch” of the bar may be too much
Begin with Horizontal Pressing where the hands are free to rotate and move to more vertical pressing over time…
- Dumbbell Bench Press
- Landmine Press
- Wall Slides
- Bottoms Up Pressing is beneficial due to the irradiation from the grip strength required along with the lower weights used because of the balance component
- *Kettlebell vs. DB vs. Barbell – The KB and DB allow for freedom of movement. The shoulder is a rotational joint and enjoys more ROM than any other joint in our body. The barbell movements are great for putting on mass & strength, but they lock down the shoulders and wrists. The kettlebell also has an extra benefit. Due to the weight being on the outside of the wrist, the external rotators are activated. This does not happen with the DB or BB.
Grip Strength correlates directly to rotator cuff engagement through something called “irradiation.”
- Heavy Carries
- Rice Buckets
- DB & Barbell Complex Work
Try a Neutral Grip when doing:
- Chin Ups
- Push Ups
- Dumbbell Bench
Traditional Rotator cuff work
- The Rotator cuff is a dynamic stabilizer – to perform reactive training a certain amount of strength is needed but do not blindly do strength work. This is where assessment and working with a good physio are important.
- Progressively move from mobility & strength into reactive/dynamic work
- Farmer carrying & deadlifting cause a distraction & force coupling at the shoulder joint that utilize the stabilizers at a non-provocative angle. Move to hanging when ready. Our arms were made to hang, but the angle can be too much too soon for some.
- When getting back into compression on the shoulder start with TGU's, planks on hands or elbows, baby crawling (hands and knees) and slowly work your way back up to more difficult positions & loads.
Put a mini-band on around the wrists when doing:
- Push ups, Planks, Benching, Crawling
- This will activate the lats and serratus anterior.
- It's a wonderful teaching tool but don't rely on this as a crutch. As the client/athlete improves try to use it less and less
- Light ropes (small motions)
- Tempo running
- Sideboard – but be very mindful of falling.
- Sleds – be careful of too much compression on the shoulder
- Rowing – harp on quality only if used, not time
- Coach diaphragmatic breathing techniques first as they will carry over into everything you do. Your breathing muscles connect to the rib cage and neck. Very important to address breathing as it is a part of a large global chain that could be causing dysfunction.
- 90/90 Breathing – feet on a wall or bench
- Crocodile Breathing
- Supine Breathing
- Child's Pose
- Quadruped Breathing
- 3 Month Position
- The Front Plank can be too much compression, but when done on a stability ball it can take some of the pressure away.
- By using the ground as your “core”, you're able to put your spine in a good position not allowing you to compensate through the shoulder girdle, lumbar spine, or neck.
- Breathing Drills
- ½ Kneeling core work (See #5)
- Use the ground as your “core”. You're able to put your spine in a good position and take the knee out of the equation completely
- Crawling Variations
- Body Saws/ Stability Ball Work/ Rollouts/ Planks
- Anti-Rotation & Push/Pull
- Activating the Upper Body before moving your lower body is a good way to 1. lock down your core and 2. get light upper body training without making the problem worse.
- Leg Lowers
- Dead Bugs
- Lying Hip Flexion
- Hip Lifts
- Half kneeling exercises and stretches
- Crawling – begin on the hands and knees (6-point) and work your way to the more difficult version with the knees off the ground (4-point). Crawling helps to integrate the contralateral pattern in a safe and easy progression.
- Bear Crawl
- Lateral Crawl (“bear” position or push up position)
- *Avoid if compression on the shoulder causes pain.
- Half kneeling core work where you cross the midline is like candy for the brain.
- ½ Kneel Chop & Lift, Row, Chest Press
- ½ Kneeling Landmines and Anti-Rotation Holds
- ½ Kneeling Medicine Ball Slams
- Light Carries
- Farmer Carries
- Goblet Carries
- Most importantly coach them on how to pick them up and put them down.
Packing the neck
- Neck has a direct link to your shoulder and ribcage
- On exercises like planks, push ups, swings, deadlifts, it is best to try and keep the head in line (neutral) with the spine
- Using a PVC is a wonderful teaching tool to make someone aware of their spine
When working with the joint-by-joint approach the shoulder is comprised of many things.
Primarily the scapula, glenohumeral joint, thoracic spine, and secondary are the cervical spine, elbow, and wrist.
The scapula & lower cervicals, and elbow are meant to be more stable. The glenohumeral joint, thoracic spine, upper cervicals, and wrist are more biased towards mobility. If the upper cervicals, thoracic spine, wrist, or GH joint lack MOBILITY the shoulder joint will more than likely will have to pick up the slack. If the scapula, lower cervicals, elbow or core are not STABLE the shoulder will again pick up the slack.
Some of our favorite drills are provided below
Thoracic spine mobility:
- Quadruped T-spine rotations – External & Internal variations
- Peanut or Tennis Ball Extensions
- Bench T-spine Stretch
- ½ Kneeling Windmill
- PNF sleeper stretch
- Band Lat stretch
- Controller Articular Rotations
- Indian Clubs
Neck Mobility (Upper):
- Neck Nods
- Slow Full Rotations
- Segmental Rolling
Neck Stability (Lower)
- Packing the neck (see #9 above in the core section)
- Push Up Position Holds
- TGU's & Arm Bars
- Hanging Scap Retractions
- Learning to “pack” the shoulder in deadlifts & swings
Lumbar Stability & Breathing as it integrates with positioning of the cervical spine, rib cage, & pelvis
- See #8 above in “Things to Troubleshoot”
*Note these mobility, flexibility, and low-level stability drills are all done for breaths and NOT for time. Breathing is the only way we can consciously regulate the autonomic nervous system to relax. Coach breathing during the initial phases of your training and it will carry over into everything else you do.
Slowly begin to add in more explosive and heavy work as the client progresses. Some exercises may never again be possible and will always be contraindicated for that individual. That is the reality. Set your goals high but have realistic expectations. Trial and error will be a part of the process. Use our Phase 1 Intro Adult Program and regress or eliminate from there. Remember when training someone with shoulder pain to avoid exercises that could compromise the joint the while working with a good doctor, therapist, or both to restore function.
The accompanying example program is our Intro Phase One Adult Program. The contraindicated exercises have been replaced with exercises that may be a better choice. Remember, each person is different. There is no timeline on when it's appropriate to progress. The provided program is a great place to start. Regress and progress as needed, with the end goal being to get every client into our Returning Adult Program pain-free and without any compensations.
Interested in learning more? At our Certified Functional Strength Coach course you will experience 8+ hours of hands-on coaching. We will take you through each of the regressions and progressions mentioned above and share with you the system we use to train large groups of clients and athletes.
This article was written by CFSC Coach Brendon Rearick. He can be contacted at firstname.lastname@example.org