Most athletes that participate in collision and high impact sports, such as football, ice hockey, mogul skiing, and downhill mountain biking, commonly see acute and repetitive trauma injuries to the acromioclavicular joint. Other common shoulder injuries reported are, impingement syndrome, A/C problems, shoulder instability, and bicep anchor damage (SLAP lesions).
In these cases the sports medicine professional, Athletic Trainer, or Strength & Conditioning Specialist should be able to make correct decisions on the progression of a rehabilitation program, and the prevention of subsequent injuries from weight training.
The following are some modifications of the bench press, shoulder press, and lat pulldown. Many times these three movements along with other multi-joint exercises are main components in an athletes periodization based training program.
Benching with a straight bar places a tremendous amount of stress on the humeral head stabilizers of the rotator cuff (infraspinatus, supraspinatus, subscapularis, and teres minor), and the long head of the bicep brachii muscles. One repetition, max lifts (1RM) can attribute significantly to shoulder lesions, and should be limited to 2-3 times a year or avoided all together. The risks on 1RM lifts typically outweigh the benefits.
Anterior shoulder instability:
a) The athletes hand spacing should be no wider than 1.5 biacromial width. This will minimize peak shoulder torque in pressing motions. Biacromial with is measured from the superior portion of right acromioclavicular joint to the left acromioclavicular joint. The distance between the two acromioclavicular joints are considered 1x biacromial width.
b) Having the trainer assist the athlete to lift the bar from bracket, is what is called a “Mandatory handoff”, and will prevent shoulder subluxion, and dislocation.
c) Incline Bench pressing should be avoided
d) Supine and decline bench press should be systematically alternated every other training session that involves chest work.
e) Be certain of proper form. The barbell should be lowered slowly to sternum, 2-3 inches superior of xiphoid process. Press bar upwards, in line with shoulders, and maintain a “five point” contact throughout the entire lift.
Posterior shoulder stability:
a) The athletes hand spacing should be increased to be 2x biacromial width. This angle will allow better structural approximation of the humeral head in the glenoid fossa, and decreases the strain on the posterior soft tissue.
b) Perform a mandatory handoff.
c) Perform this lying in the supine position only, no incline or decline pressing.
Slap lesions (superior labrum antero-posterior lesions), glenoid labrum and bicep anchor damage:
a) Same guidelines as anterior stability.
b) The athletes grip should be varied from underhand to an overhand grip on alternate days. This will decrease the micro-traumatic injuries and stress on the long head of the biceps tendon.
c) The overhand grip removes the bicep tendon from beneath the acromion by internally rotating the humerus, but due to the full pronation of forearm, it stresses the attachment of the long head of the biceps.
d) The underhand grip places the long head of the biceps tendon (supination) in a preferred position to decrease the stress on the tendon, but places the long head of biceps tendon beneath the acromion, allowing it to impinge.
e) Overhand and underhand grip should not be used in same day and should follow a periodization protocol.
The barbell shoulder press starts with hand spacing slightly wider than shoulder width. Starting position is when bar is at the anterior portion of the deltoids, and sternoclavicular joints, and it is pressed overhead. Behind the neck shoulder press should be avoided all together due to the physiological effects of this movement, until full function is achieved. It should be replaced with posterior deltoid specific exercises, such as rows, rear deltoid raises, and dumbbell rows.
The barbell shoulder press starts with shoulder abduction, in the “high 5 position” and external rotation. This position places significant strain on anteroinferior glenohumeral ligaments. It also stresses the cervical region, by placing the head into excessive flexion, and stressing the rotator cuff through the impingement mechanism. The high 5 position is when the athlete has their palms pronated outward, facing away from them, at about chin level, with the arms in the saggital plane.
Modification of movement
a) A functional isometric program is implemented within the confines of a power rack, and performed by athletes that are required to perform overhead movements.
b) Two sets of pins are set up in rack. One to support the weight, and one to limit range of motion starting at 60 degrees of shoulder flexion and one at 120 degrees. This provides minimal torque in external rotation and provides significant glonohumeral joint approximation.
c) An isometric hold of 5-10 seconds is held per repetition at each angle, and 6-10 repetitions performed at each of the three 60, 90, 120 degrees.
d) Be sure to watch for resistance training machines with excessive high five positions, and internal rotation. Machines that typically have safe positions are Nautilus, Hammer Strength, and Hoist Roc-it strength machines.
LAT PULL DOWN:
This exercise involves a combination of movements in the saggital plane (flexion/extension), and the coronal plane (adduction/abduction). The bar is pulled from overhead to the base of the neck to the first thoracic vertebrae or just inferior of the clavicle .The behind the neck pulldown should be avoided for similar reasons as the behind the neck shoulder press. Pulling the bar behind your head and forward tilting chin to far anterior, can create excessive compression in the shoulder complex and cause transient brachial plexus nerve impingement (TBPNI). Transient upper extremity paralysis after completion of behind the neck pull downs is typically noticed in the hands first.
Modification of movement
a) Start with the upper body in a 30 degree reclined position, with bar inline with xiphoid process.
b) Handgrip should be 1.25-1.5 biacromial width.
c) This position prevents athlete from being in high five position, and increases the activation of the shoulder adductor and scapular retractor muscles which assist in stabilizing the humeral head throughout the movement.
d) Raise bar slowly upward, and increase elbow flexion as much as possible, just before scapular elevation occurs. Otherwise this can cause instability in the glenohumeral joint.
e) For the reverse grip pulldown, the hands are placed at 1x biacromial width, and the start and end positions are performed in the same manner.
Remember these are modifications for competitive athletes for these three particular movements, and after the completion of physical therapy. They must also be done under the supervision of a sports medicine professional. If the athlete experiences acute pain while performing these exercises, then they should stop, and consult their physical therapist, due to the fact that they may not yet, be ready to perform these particular motions.
Jon Torerk, CSCS