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Shoulder Impingement Syndrome

By Dr. Clay Hyght
First published at www.johnberardi.com, Nov 17 2003.

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There are some injuries that are, unfortunately, very common in the gym. Among those who consider going to the gym their “social time,” two are very common: overuse of the lateral and medial rectus from sneaking glances at spandex-clad hotties and T.M.J. from excessive use of the jaw (talking to dang much) are often seen. However, for those of us who actually go to the gym to train, we suffer from other maladies. Specifically, shoulder injuries are probably the most common. And among the common shoulder maladies, one type occurs with far more frequency than all others: shoulder impingement syndrome (SIS).

If you, a client, or a friend has shoulder pain and are wondering if the shoulder pain could be due to SIS, here are a few clues to look for. First, the most common exercises that aggravate SIS are overhead pressing movements, flat barbell bench presses, and lateral raises. With severe SIS these movements as well as just about any exercise involving movement of the shoulder joint can cause pain. That's right, as a weight trainer, the last injury you want this one. Obviously, there's very little you can do, in terms of lifting, if you're suffering from SIS.

If you need more to make your self diagnosis, try this orthopedic test. Raise your arm in front of you (the bad shoulder, dummy) to an overhead position while keeping your pinky up and thumb down. If that movement hurts or is impossible due to pain, then you likely have some degree of shoulder impingement.

Now, some guys think it’s macho to just train through pain. But, while getting your nipple pierced without flinching would make you quite cool, trying to train through SIS isn't cool at all. It's downright stupid. This is one of those conditions that only gets worse with use. Complete time away from the gym may be necessary to see progress in the right direction. But don't worry, my friend, I'm not gonna leave you hangin’. Dr. Feelgood is in the house to show you how to correct and yes, even prevent Shoulder Impingement Syndrome.

Shoulder Biomechanics

Impingement syndrome is defined as a compromise of the space between the head of the humerus and the acromial arch. In simple terms: the top of your upper arm bone is too high and close to your acromion (part of the shoulder blade-scapula) and your clavicle (collarbone). This decrease in space can come from either a structural problem (usually bone) or a functional problem (usually muscular). Since a structural problem would likely show up as soon as someone begins lifting weights, we’ll focus on functional causes of impingement, which are most likely the culprit in the gym.

When you raise your arm, a complex chain of events takes place. A group of muscles called the scapular stabilizers (serratus, trapezius, levator scapulae, rhomboids, and teres major) function in a very precise manner to ensure that the scapula is in the right place at the right time. At the same time, the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) finely coordinate the movement of the humerus to ensure proper alignment in relation to the scapula.

If these muscles do not coordinate this movement perfectly, the head of the humerus is likely to rise up and forward and bump into the bottom of the acromion. (To feel the top of your acromion, slide your fingers from the middle of your collarbone outward toward your deltoid. Just before getting to your deltoid you will feel the top of your acromion sticking up a bit.) When this impingement occurs, the supraspinatus muscle and tendon, as well as the subacromial bursa, are trapped between the humerus and the acromion. When two soft structures are trapped between two bony structures, you can guess who loses. This results in swelling and tenderness of this bursa (bursitis) and the supraspinatus muscle and tendon (tendonitis).

Strength

The way to ensure that the scapular stabilizers and the rotator cuff muscles can do their job is to make sure that these muscles are strong and flexible. Let’s begin with a sample strength and flexibility program that may help to prevent or correct impingement syndrome.

Train your rotator cuff two times per week (for example: Monday and Thursday.) You might even work your way up to doing this routine three times per week (for example: Monday, Wednesday, and Friday.) The two basic exercises for rotator cuff are the sword and the seatbelt exercises. They are to the rotator cuff what squats are to the legs.

To perform the sword exercise, begin with a handle attached to a pulley set at the lowest position on the cable crossover machine. To exercise the right rotator cuff, stand with the pulley on your left-hand side. Reach across the front of your body and grasp the handle with your right hand. This will be the starting position. Begin the exercise by raising your arm up and out to the side. You should end up with you arm slightly (about 30 degrees) above horizontal and your palm facing forward. Your arm will basically be at the “Y” position of the YMCA dance maneuver. If you’re not sure what that is, go to your nearest retro dance club and request the song YMCA by the Village People. Then you’ll see what the “Y” position looks like. This exercise is called the sword because its execution resembles taking a sword out of its sheath.

To perform the seatbelt exercise, begin with the handle set just above head level on the cable crossover machine. This time, to exercise the right cuff you’ll begin with the cable on your right side. Reach up and grasp the handle with your right hand with your palm facing forward. Your arm should be about 45 degrees above horizontal (the “Y” position.) Begin the movement by bringing your arm down and across to the left. This will resemble fastening your seat belt in the passenger seat of a car. You’ll end up with your palm facing your body with your hand just in front of your left hip.

Another good cuff exercise is the empty can exercise. If you are currently suffering from shoulder pain, you will likely need to wait until some of the pain subsides before attempting this exercise. To reiterate, this exercise should not be painful, and neither should any of the others for that matter. To execute the empty can begin with your arm at your side and rotated inward. Begin the movement by raising your arm up at an angle about halfway between the sagital plane and the frontal plane. To find this plane of movement, raise your arm straight out to the side as if you were doing a lateral raise. Now bring that arm forward 30 - 45 degrees. This is called the scapular plane and is the plane in which you want to perform this exercise. As you are raising your arm up (abduction) in the scapular plane, keep your arm internally rotated which means your pinky will be up and your thumb down (as if you were emptying a can.)

All rotator cuff exercises should be performed with a weight that allows you to get 20 reps without much difficulty. Perform all rotator cuff exercises very slowly (about 5 seconds on both the positive and negative portion of the repetition.) Perform three sets of each exercise. Keep in mind that the goal in training the rotator cuff is more to train the muscle to fire properly than to build the muscle. Save your all-out hardcore training for another body part.

Flexibility

Flexibility of the shoulder is just as important as strength. To keep the rotator cuff complex flexible, try the following stretches.

With your humerus at an angle of about 30 degrees (this will put your elbow about six inches from your side) and your elbow bent to about 90 degrees, have a partner lightly internally rotate your arm (your hand will end up behind your back in this stretch.) Hold a slight stretch for about 30 seconds. With your humerus still at 30 degrees and elbow at 90 degrees, have your partner rotate you arm externally (hand going out to the side) and hold for about 30 seconds.

The other two stretches are the exact same except your humerus will be at 90 degrees of abduction (straight out to the side as if finishing a lateral raise.) Again lightly stretch internally and externally holding each for about 30 seconds. Repeat each 30-second stretch two times. That’s a four stretches held 30 seconds each and repeated. A total of four minutes of stretching that will go a long way toward pain-free shoulders.

To put the finishing touches on achieving a healthy shoulder complex, you should make sure that you stretch your chest often and strengthen the muscles between your shoulder blades - the rhomboids and the middle and lower trapezius. You should already know how to stretch your chest, just do it more often. To strengthen the upper back muscles concentrate on exercises like bent-over flyes and rows with your arms parallel to the ground. In other words, exercises that bring the shoulder blades toward the spine.

Lastly, if you are currently suffering from shoulder pain, icing your shoulder may help reduce pain and inflammation. Place a damp washcloth on the affected shoulder. Place an ice pack or bag of frozen vegetables on top of the damp washcloth. Leave this in place for 20 minutes or until your shoulder goes numb, whichever comes first. Longer is not better! The most important time to ice the shoulder is after any workout involving the shoulder complex. However, you can also ice it throughout the day but not more than once per hour. NSAIDS (non-steroidal anti-inflammatory drugs) can be used for a week or two to help decrease inflammation and pain. After two weeks NSAIDS basically act only as an analgesic (pain reliever) and may actually delay tissue healing. Whatever you do, don’t rely on NSAIDS to get you through your workout!

Exercise Selection

There are certain exercises that have a tendency to cause or aggravate shoulder impingement. For starters, unless you're dying to know what this injury feels like, never do behind-the-neck presses. Next, any shoulder press where you elbows are straight out to the sides can aggravate the condition. A safer press can be done by keeping your elbows more to the front - as when doing Arnold Presses. Most shoulder press machines give you two sets of handles to choose from. One set that runs parallel to your body and is wider, and another set that runs perpendicular to your body and is narrower. For the sake of shoulder safety, use the narrow, perpendicular handles and keep your elbows in front of your body as opposed to beside it as with the wider handles. Lastly, you may have to put your ego to rest and not perform standard bench presses. Although not benching is a sin in many weight-lifting circles, benches seem to be the culprit in many shoulder injuries. Instead, try inclined BB presses, which seem to be less injurious to the shoulder complex. Besides, your upper pecs could probably use the work.

Supplementation

A more natural way to reduce the pain and inflammation is to take a Glucosamine (1,500 mg) and Chondroitin (1,200 mg) supplement daily. Not only has this combination been shown in numerous clinical studies to decrease pain and inflammation, it also provides the body with the "raw materials" it needs to build new, healthy connective tissue. If you really want to cover all your bases, you could add MSM, which supplies sulfur to the connective tissue. You can buy all of these separately, or you can get all of them in Labrada's ElastiJoint drink mix. In addition, ElastiJoint has almost 1,000 mg of Vitamin C and 5,000 mg of collagen, both of which support healthy joints. For the record, I have no vested interest in Labrada products, but I know a good product when I see it. If you prefer, buy all of these ingredients separately from other reputable manufactures. Lastly, you may want to supplement your diet with fish oil capsules to provide your body with the Omega-3 fatty acid. This essential fatty acid has been shown to have potent anti-inflammatory effects - just what you need! For starters, shoot for 3,000 mg taken 3 times per day with meals.

The above information is provided for educational purposes only and is not meant to take the place of a visit to your local doctor. Again, if you have shoulder pain you should see your doctor.

Until next time, train hard and train smart!

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Along with being a Doctor of Chiropractic and Certified Strength and Conditioning Specialist, Dr. Hyght is also a national-level bodybuilding competitor and fitness model that writes for a various fitness publications. To learn more about Dr. Hyght or to contact him, log on to www.DrHyght.com.