Welcome back to Squat University. Last week I began writing on the topic of shoulder pain. Today I want to take our next step in the journey to fix those achy and painful shoulders by learning how to properly screen your body to uncover why your symptoms started.
The way we’re going to go about doing this will be similar to the methodology introduced during the back pain blog series (if you are currently dealing with back pain I highly recommend going back and checking those out). The approach is quite simple, instead of trying to diagnose the specific part of the shoulder that may be injured (such as the labrum or rotator cuff) we need to uncover the root cause of the pain.
By addressing the why behind the pain we can hope to avoid tunnel vision in our rehab plan. For example, someone dealing with an irritated rotator cuff after performing a number of push presses may start performing some standard shoulder strength work they found online. However, if the inflammation was caused due to an impingement because of poor thoracic spine extension (and therefore an inability of the shoulder blade to sufficiently glide upwards) no amount of strengthening for the rotator cuff muscles work would truly fix the issue. The pain may subside in the short-term but would likely return as soon as the athlete returned to lifting overhead again.
In physical therapy school we are taught to perform a battery of tests to rule in or out specific injuries. However, many of these tests only serve to confirm the presence of a specific injury (labrum or rotator cuff tear) rather than to help identify the underlying injury mechanism! Knowing someone has a rotator cuff tear doesn’t necessarily tell me why he or she has pain or what needs to be corrected. Therefore, screening and classifying an injury by the problem that is causing the pain (an inability to raise arm overhead due to thoracic spine extension mobility) is more useful to driving the treatment process than knowing the exact anatomical cause of the pain (rotator cuff pathology).
During the screening process we will now go through, I want you to think about which of the following categories best fits your shoulder pain. Each test can give you clues on how to piece together a plan of action to fix your injury.
- Limited Mobility
- Instability
- Strength Imbalance/Weakness
- Poor Movement/Technique
Lifting Assessment
You’ve likely started reading this blog post because you’re experiencing shoulder pain when lifting. Assessing the quality of your technique should be our first step in trying to uncover the cause of your injury.
Think about all of the repetitive lifts or movements you do in the gym that create shoulder pain. Once you’ve placed your finger on the one or two things that lead to pain, can you find a common movement or posture you assume during them? For example, a weightlifter who has shoulder pain when performing an overhead squat or snatch may do so because of positioning the bar too far behind their head leading to the humerus “ball” sliding forward (anterior) in the socket “tee.” If this sounds like you, see if your symptoms change when modifying your technique by bringing the bar into a more stacked position over the back of your head in line with your shoulders/scapulae.
When you assess your lifting technique, make sure you observe everything from your wrists down to your lower back. Each of these components (as you will read about soon) can have an impact on the forces sustained at the shoulder joint. Having another set of eyes from a skilled coach can be helpful at identifying small problems in technique that could be the cause of your symptoms.
Seated Assessment
In the sports of weightlifting and CrossFit, there is a ton of overhead lifting performed in variety of positions (wide grip with the snatch and close grip with the jerk or press). If an athlete does not have adequate mobility to perform these lifts a number of injuries can eventually occur.
The screen I want to share with you today is one I first saw demonstrated by physical therapist Dr. Dave Tilley of Shiftmovementscience.com (and happens to be a variation of one of the mobility screens I shared in my first book The Squat Bible)
Start by sitting next to a wall. Your upper back, head and hips should be in contact with the wall. You should have neutral lower spine (this means you don’t need to jam your low back into the wall).
With your arms extended in front of you and palms facing the ground, raise your arms as high overhead as you can. If you’d like, you can do this with a PVC pipe and the same grip you would use for a clean & jerk or overhead press. Keep your core braced and ribs from flaring out as you perform this movement.
Could you make it all the way to the wall without your arms bending? If you were able to touch the wall behind you, did it take a ton of effort? If you answered yes to both, try the same movement again but with your palms facing towards the ceiling (this is a more externally rotated shoulder position). If you have access to one, grab a PVC pipe again and hold it with your palms facing the ground (reverse grip)
Were you able to still reach the wall?
Did your elbows end up bending? Did your head have to pop forward off the wall or your arms move out to a “Y” position in order to have your hands touch the wall? If you didn’t have a PVC pipe to hold, did your thumbs want to turn towards your head (shoulder internal rotation) as you raised your arm overhead?
You should ideally be able to have your arms remain close to your ears while you raise them to the wall behind you (similar to a narrow grip on an overhead press). This should be an effortless motion that doesn’t require much grunt force to complete. If this was you, congratulations. You have adequate overhead mobility!
Next, place your arms on the wall in an “L” position. Slide your arms down the wall as far as you can without losing contact with the wall.
What did you experience?
This motion is mimicking the arm positions necessarily to efficiently hold the barbell on your back during a back squat. If you were unable to slide your arms to at least a 45-degree angle without compensation (rib flair or low back arch) it means you’re likely missing mobility somewhere. This could be due to limited shoulder external rotation, thoracic spine extension or pec major/minor flexibility (something we’ll go over soon).
While the past few screens focused on the importance of shoulder external rotation, the weightlifter and CrossFitter must also have a sufficient amount of internal rotation in order to keep the bar close to the body during the Olympic lifts (especially the snatch). If an athlete is missing adequate internal rotation of the shoulder, they will have to compensate by rolling their entire shoulder complex forward (by excessively moving their shoulder blade) in order to keep the bar from looping away from the body.
To screen for your internal rotation, slide your arms back up to that 90-degree “L” position and rotate your hands as far toward the ground as you can without your shoulder blades popping off the wall. Ideally, you should be able to internally rotate your shoulder and the forearm to at least reach parallel relative to the ground.
If you were unable to pass any of these prior screens, proceed to these breakout screens to determine what is limiting your mobility.
Lat/Teres Major Flexibility Testing
While lying on your back, have a friend raise your arm overhead while they hold your shoulder blade from moving with their other hand. Perform this movement with your thumb facing the sky and also with your thumb facing away from the head (this means we’re assessing shoulder elevation in an internally and externally rotated position).
Were you able to move the arm higher overhead when the thumb was facing the sky? This internally rotated position takes slack off the lats and teres major muscles and therefore allows someone with flexibility limitations in these muscles to move their arm further overhead.
If arm elevation was limited with no significant difference between the two tests, it is possible the mobility restriction may be coming from deeper in the joint (such as a stiff/restricted joint capsule) that would require a rehabilitation professional to address appropriately.
Pec Minor & Major Flexibility Testing
Sufficient flexibility of the small pec minor muscle is imperative for proper shoulder blade mechanics when lifting. An inflexible pec minor will lead to an inability of the shoulder blade to adequately move (leaving it protracted and anteriorly tilted) and lead to early impingement of the small structures in the shoulder joint.
To assess the flexibility of this muscle, start by lying on your back with your hands placed on your stomach and your elbows bent. Placing your hands like this will take slack off of the coracobrachialis and the “short head” portion of the biceps brachii (two small muscles that attach to the top of the shoulder and could contribute to a false positive in this test).
Have a friend place their palms across the tops of your shoulders (over the bony part that sticks out called your coracoid process) and push down. If there is sufficient flexibility of this small muscle the shoulders should be easily pushed to the ground without any sensation of excessive muscle stretch in the upper chest.4
While the pec minor attaches to and affects the position and movement of your shoulder blade, the pec major attaches directly to your arm bone (humerus). This means stiffness in this muscle will roll the arm and shoulder joint inwards into a poor postured position.
Start by lying on your back with your hands clasped together behind your head. Allow your elbows to relax as far toward the ground as possible. This test is positive for a short/stiff pec major muscle if you cannot easily touch your elbows to the ground.4
Keep a mental note of whether you found stiffness in either the pec minor and/or major as each will require a slightly different variation in body position during stretches that I will show in upcoming blogs to effectively improve flexibility.
Thoracic Spine Mobility Testing
Mobility of the thoracic spine can be difficult to assess as it’s composed of multiple spinal joints. The architecture of this portion of the spine is naturally stiff in order to keep our vital organs safe. However, if this area is too stiff it will affect the movement of the shoulder blade and compromise movement and stability of the shoulder joint.
While it’s difficult to measure spinal extension, we can measure rotation to give us an idea of how well the spine is moving. This is because each spinal joint moves on top of each other in a similar fashion during rotation or extension. Try this simple assessment to test your mid-back rotation.
Tape an “X” on the ground with the edges forming 90-degree angles. Sit in the middle of the “X” so that the tape forms a “V” in front of you. Place a PVC pipe across your chest (as if performing a front squat with a cross-arm grip) and rotate as far as you can to the right and left side.1,5
Ideally you should be able to rotate your T-spine 45-degrees each way (this will align the PVC pipe with the tape on the ground).
Instability Testing
The stability of the shoulder joint is created and maintained by both active and passive forces. Active stability is something we can work on and modify (by increasing or decreasing muscle force). Passive stability we have zero control over (i.e. ligaments, shoulder capsule, labrum and the bony anatomy of the shoulder joint).
Athletes with hypermobility (either congenital or acquired over time) often have less stability from these passive structures. A hypermobile joint can be prone to injury if the athlete does not work on his or her active stability.
A simple test to determine whether your body was naturally born with hypermobility in these passive structures is the Sulcus Sign. While in a seated or standing position with your arm relaxed by your side, have a friend grab your arm and slowly pull down. The goal is to see if this downward pull creates a noticeable gap between the humerus bone and the top of the shoulder. A positive “sulcus” is seen if the space created between these two areas produces more than a finger width (8-10mm) gap.2,4
Even though this specific test is assessing the laxity of the lower or inferior capsule of the shoulder joint, several researchers have noted that those with instability in this direction almost always have excessive movement in other directions (called multidirectional instability or MDI).2,4 For this reason, those with a positive Sulcus Sign require stability and strength exercises to improve their control of the joint. These athletes almost always have normal range-of-motion in their shoulder and therefore should not be stretched (even if they “feel tight”) as doing so will likely lead to even more instability and pain in the future.
Strength Imbalance Testing
One of the most common strength imbalances that leads to shoulder pain is the “anterior dominant” athlete. Poor posture and training habits (focusing too much on developing the chest and deltoids) leads to anterior muscles overpowering the weaker back muscles. The back muscles include the posterior rotator cuff, rhomboids, mid/lower trapezius, and teres major. Too often, regular gym goers and atheltes over train their pecs and deltoids without giving enough time training their scapular muscle and back muscles. These back muscles ensure proper stability of the scapula and prevent forward shoulder. The posterior rotator cuff also ensures the glenohumeral joint (shoulder joint) is properly stabilized. Two simple tests you can do at home to assess the strength in of these posterior shoulder muscles are the T & Y screens.
Go ahead and get down in a quadruped position (on your hands and knees). Hold one arm directly out to your side (as if making one side of the letter T). Make sure your palm is facing toward the ground. Have a partner then push down on your outstretched arm for 3 seconds. Resist the force that your partner is exerting on your arm! Did your arm easily drop or were you able to stabilize against his or her force?
Next, take your outstretched arm and move it to an elevated position (as if now making one side of the letter Y). Again, have a partner push down on your outstretched arm for 3 seconds. Try to resist this movement as much as you can!
What did you feel? If you had a hard time keeping your arm from moving, it means you may have poor scapular stability due to weakness in the posterior shoulder and upper back muscles.
Next, let’s look more specifically at the the muscles deep inside the shoulder (rotator cuff). If the rotator cuff is weak the stronger muscles that surround the shoulder (such as the deltoids) can overpower the smaller cuff muscles and injury can eventually follow.
Poor shoulder external rotation strength is a big culprit for a vast majority of shoulder pain. Most clinicians screen for this problem with the athlete’s arms by their sides. With your elbows bent to a 90-degree “L” position, try to resist any movement of your arms as a friend tries to force your hands together.
Were you able to hold your arms straight forward or did your hands easily collapse inwards? Was one side weaker than the other?
Try the test now with your arm in an elevated position. Make that same “L” position with your arm but move it to shoulder height as if making a “high five.” Again try to resist any movement as a friend now attempts to push your hand forward (attempting to create shoulder internal rotation).
What did you find this time? Was it harder to control your arm with it elevated? The elevated shoulder position increases the challenge of the rotator cuff to provide stability for the joint. Your shoulder muscles must work harder in an elevated position. Consequently, your shoulder is more likely to get injured in an elevated or overhead position. On a side note, a majority of shoulder dislocations occur when the arm is away from your body and your shoulder is naturally in a “loose packed” position.
Another common screen to assess the rotator cuff strength and stability (specifically of the supraspinatus muscle) is the “full can” test.3,4While standing, raise your arms to shoulder level in a “V” shape with your thumbs pointed to the ceiling. Hold this position as a friend attempts to push your hands down towards the ground. Those who have a weak and/or injured rotator cuff will be unable to keep their arm from moving!
The last strength test we will perform will be for the serratus anterior muscle. As the arm elevates above the head, the serratus anterior works with the trap muscles to move the shoulder blade into an efficient position to provide stability for the shoulder joint (aiding specifically with upward rotation and posterior tilt of the scapula). If the serratus isn’t working correctly, the shoulder blade will fail to rotate and tilt appropriately, which will limit overhead range-of-motion and create impingement in the joint itself. Often athletes with weakness in this muscle will over compensate with their upper traps when pushing a barbell over their head.
To assess strength of this specific muscle, stand with your shirt off (or wear a small tank-top). Raise your arm in front of you to just above shoulder height and hold it there. Have a friend grab your arm with one hand while feeling for the bottom angle of your shoulder blade (called the inferior angle) with their other hand. Have your friend apply a force down and back (towards your body) while you resist. Watch what happens to the shoulder blade. If the serratus is weak, the inferior angle of the shoulder blade will rotate down and pop off the back (a motion called winging) or the upper trap will shrug upwards as a compensation. Perform this test as well as with the arm elevated to ear level to ensure we’re evaluating the strength of this muscle in similar positions needed for overhead barbell training.
Final Thoughts
Now that you have this newfound knowledge of what creates your pain, we can start to craft together an efficient rehabilitation plan that is right for your body! This will be our topic for next week’s blog!
If your pain is very severe or the shoulder weakness is significant, you should seek medical advice from your doctor. Also, if you have any nerve like pain or numbness down your arm (which can reach your fingers), please seek medical treatment ASAP. Any nerve like pain can be coming from your brachial plexus or even your cervical spine. You must take radiating pain seriously, stop training and get help.
Until next time,
With
References
- Johnson KD, Kim KM, Yu BK, Saliba SA, et al. Reliability of thoracic spine rotation range-of-motion measurements in healthy adults. J Athl Train. 2012;47(1):52-60
- Emery RJ, Mullaji AB. Glenohumeral joint instability in normal adolescents. Incidence and significance. J Bone Joint Surg Br. 1991;73(3):406-8
- Itoi E, Kido T, Sano A, Urayama M, et al. Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon? Am J Sports Med. 1999;27(1):65-8
- Magee DJ. Orthopedic Physical Assessment: 5th St. Louis, MO: Saunders Elsevier; 2008.
- Johnson KD, Grindstaff TL. Thoracic rotation measurement techniques: clinical commentary. N Am J Sports Phys Ther. 2010;5(4):252-6
- Cools AM, Cambier D, Witvrouw EE. Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. Br J Sports Med. 2008;42:628-638
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