Shoulder Pain? Fix This!

This is an older article that I still refer to. It was one that really opened my eyes to the importance of shoulder health. If you are having issues with your shoulders, chest tightening, or just generally sit at a computer all day, use some of these tips to correct yourself before you wreck yourself. Sorry, couldn't help myself. Enjoy!

Push-Ups, Face Pulls, and Shrugs
...for Strong and Healthy Shoulders!
by Bill Hartman and Mike Robertson

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Screw the Rotator Cuff!

That's right, screw it. Seriously, it's about as over-hyped as Kevin Federline's big "debut." We think the rotator cuff gets way too much attention. Whenever shoulder pain creeps up, what's the first thing that everyone brings up? The rotator cuff, of course. (Or for those of you from Indiana, that would be your "rotary cup").

"My shoulder hurts when I bench press."

"Well, you need to strengthen your rotator cuff."

"It hurts when I reach overhead or do barbell presses."

"You're probably impinging your rotator cuff."

"I hurt my shoulder pitching and now I can't collect my million dollar performance bonus."

"Sounds like you tore your rotator cuff."

We've had it up to our shoulders with the rotator cuff! While the rotator gets all the chicks, all the glamour, and all the attention, the real star of the show is forced to the background. In fact, it never even gets any mirror time at the gym, unless you're picking at your backne. (We've seen you do it).
Allow us to introduce the real star of the show: the scapula!

Our Favorite Bone

The scapula is our favorite bone and we're not afraid to admit it. (Insert way-too-easy penis joke here.) No other bone in your body functions like the scapula, nor does any have so complex or important a job. Without the scapula, your shoulder is nothing!
When you really examine the scapulae (plural for scapula), one of the first things you'll notice is that it's position on the body, and it's function, are almost entirely determined by the function of the muscles attached to it. If it weren't for your tiny acromioclavicular (AC) joint and a couple of ligaments, your scapulae wouldn't have any bony attachments to the rest of the bony skeleton.
Since the scapula is half of the glenohumeral joint (the shoulder joint) and is essentially the foundation of the shoulder, this becomes an important point. Any altered scapular muscle function, weakness, or inability to position the scapula and then stabilize it results in a direct affect on the shoulder joint with dire consequences. These include glenohumeral instability leading to arthritis, impingement, rotator cuff tendonitis/tendinosis, rotator cuff tears, labrum injuries, and so on.
Rather than blindly give you a series of exercises and a program, we think it's important that you have at least a rudimentary understanding of how the scapula functions.

Functional Anatomy Surrounding the Scapulae

We live in a 3-D world, so the scapulae function in three dimensions. The scapulae tilt forward and backward, rotate inward and outward, and rotate upward and downward.
Through the combined efforts of some 17 muscles it can also protract and retract as well as elevate (shrug) and depress.
Of the typical 180 degrees of overhead reach in a healthy shoulder, the scapulae's upward rotation is responsible for about 60 degrees of it. It does so through the synergistic efforts of the "upward" rotators: the upper trapezius, the lower trapezius, and serratus anterior.
Now imagine what would happen if you were unable, for whatever reason, to get that necessary movement from the scapulae. What would happen then? In all likelihood, when one (or all) of our scapular upward rotators are weak, inhibited, or simply not able to control and produce movement like they should, impingement syndromes develop and your rotator cuff is at a significantly increased risk of injury.
Contrast this with our downward rotators comprised of the levator scapulae and rhomboids. In her text Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann discusses a phenomenon called scapular downward rotation syndrome. In essence, due to poor training, behavioral demands and flat-out poor posture, our scapular downward rotators have a tendency to become short and stiff.
Class, what does all this mean? Let's use a simple math equation to put the pieces together:
Lack of proper training for the upward rotators + excessive training and postural demands placed on the downward rotators = a recipe for rotator cuff injury!
But as bad as that sounds, it gets worse before it gets better. Let's delve even further into the matrix, looking at how the majority of us develop our training programs.

Flawed Programming

Flaw #1: Focus on external/internal rotation movements only vs. role as a humeral depression
At the risk of sounding heretical, we've got to tell you that all those internal and external rotations aren't bad, but they're not doing as much for you as you'd like to think. This is even more true if your only goal is to have a jacked physique or push around heavy iron.
Specific muscles of the rotator cuff do promote certain movements (e.g. the subscapularis promotes internal rotation, the teres minor and infraspinatus promote external rotation, etc.), but there's a bigger, more functional role that's very rarely discussed. That role is humeral depression.
Go back to our example of upward rotation — as you move your arm upward, the scapula rotates upward as well. If your rotator cuff is working appropriately, it will exert a downward pull on the humeral head, which keeps it from impinging on the acromion. If the rotator cuff is weak or inhibited, it can't exert this downward pull, and again we're left with impingement.
Luckily for you, a lot of the exercises we've included focus on the stabilizing role of the rotator cuff. But don't skip ahead just yet, there's more to learn!

Flaw #2: Ignoring the effect of the thoracic spine on the scapula and shoulder
The scapula will talk to you if you listen. It will tell you when it's SICK (yes, there really is a condition called a SICK scapula), it will tell you where you're strong, and it'll tell you where you're weak simply based on its resting position on the ribcage and how it moves, or doesn't move, when you do.
Because the scapula rests on the ribcage forming the scapulothoracic joint, the shape of the ribcage will also determine the resting position and the mobility of the scapula. In turn, the shape of the ribcage is determined by the postural alignment of the thoracic spine (upper back). This is also why we spend so much time focusing on proper alignment of the thoracic spine in our Inside-Out product line.
This makes your scapula the middleman between the spine and the rotator cuff. We already know that poor scapular mobility or stability can compromise the strength, function, and health of the rotator cuff. Therefore, to assure optimal shoulder function we must develop the relationship from the spine (inside), to the scapula, to the rotator cuff (out).
Let's look at one example of how the thoracic spine posture affects your shoulder. In a normal thoracic spine/scapular relationship, as you reach upward, the scapula tilts backwards (posterior tilt) to make space in the shoulder joint for the rotator cuff. In a case of thoracic kyphosis (rounded forward upper back), the scapula is unable to tilt backward.
The result is a closing of the gap between the upper arm bone (humerus) and the acromion and impingement of the rotator cuff. In the photos below, you can see how the athlete compensates for an inability to tilt the scapula posteriorly and fully elevate the arms by arching in the lower back. To achieve full elevation, he's most likely impinging the rotator cuff.
As spine mobility and upper back posture improved (check out the shape of the ribcage), the scapula was free to tilt backward, restore overhead reach, and reduce compensation and impingement.

Day 1	3 months	6 months

Flaw #3: Attempting to balance bench presses with rows
If you read the interview with Bill, you remember that he laid out what the basic movement pattern relationships should be based on the function of the scapulae and rotator cuff. It looks like this:

Abduction/scapular upward rotation to adduction/scapular downward rotation:

• Vertical push to vertical pull
• 0.85-0.95 to 1 (almost 1 to 1)

Protraction to retraction:

• Horizontal push to horizontal pull
• 1 to 1

For the rotator cuff:

• Internal rotation to external rotation
• 1 to 0.75

We all know that we should balance our pushes and pulls, especially with regards to our bench pressing and rowing, right? But what if it's not so simple a relationship? Do we have your attention?
In essence, what we're looking at here is balancing our ability to protract and retract the scapulae. Bench pressing is a horizontal pushing movement that you'd think normally produces protraction (forward movement of the scapula around the ribcage) and trains the muscle that cause protraction, a.k.a. the serratus anterior. The logical opposing movement would be a row of some sort. Balanced, right? Wrong.

Question: What's the most effective scapular position to maximize bench press performance?

Answer: Retraction and depression

Question: What scapular position is achieved in the contracted phase of a rowing movement?

Answer: Retraction and depression
Balanced? Nope.
Get it? What looks good on the outside, feeds an imbalance on the inside. Serratus anterior becomes ineffective as a protractor, stabilizer, and upward rotator. Then there's an added bonus. But first a quick anatomy lesson.
Next time you're cutting on a cadaver (What? Doesn't everyone?), check out the serratus anterior and the rhomboid. What you'll find is that because of the fascia that covers everything in the body, they're essentially the same muscle with the scapula kinda stuck in the middle.
So if the serratus anterior isn't fully effective at producing an upward rotation force and the rhomboid (a downward rotator) is getting trained with both pushes and pulls, then guess who wins the tug-o-war with the scapula.
Correct! The rhomboids and downward rotation. This means you're more likely to experience shoulder impingement. But that's not all!
Remember how the thoracic kyphosis limited posterior tilt of the scapula with elevation of your arm? The kyphosis will also promote an anterior tilt of the scapula at rest. Over time, the pec minor (which attaches to the front of the scapula) will stiffen or shorten and the scapula gets "stuck" in an anterior tilt.
This will also result in weakness of the serratus anterior, lower trapezius, and the upper trapezius. These, as you now know, are the upward rotators. Weakness in the upward rotators will then allow the downward rotators to become the dominant force on the scapula. If you need to figure out what happens next, please reread the scapular equation in section two of this article.
So whether you're a truck driver or a powerlifter, you can end up with the same shoulder dysfunctions.

Truck Driver	Powerlifter

The bottom line? Crappy scapular position leads to crappy scapular stability which leads to crappy rotator cuff function! As Matt Damon's character in Good Will Hunting would say, "How you like them apples?"
So what's the fix?

Long Live the Push-Up!

The push-up has been used for centuries to help everyone from cromagnon man to the ancient Greeks, to guys and gals like yourself, with one goal in mind — to achieve a jacked physique! And why not? It's an amazingly simple exercise that anyone can perform anywhere.
Unfortunately, in recent years, the push-up seems to have fallen out of favor in a lot of circles. For those who like excessively detailed programs, it's just not "complex" enough. For others, it's only for the "bodyweight" guys. And lastly, some just don't know how to fit it into their program and progress it correctly.
Before we get onto the push-up and its progressions, let's look at some of the research that's been done regarding push-ups. Obviously, our first goal of performing push-ups is to recruit and strengthen the serratus anterior. So how can we do that?
Lear and Gross determined that push-ups performed with the feet on an elevated surface (in this case the feet were elevated 45.7 cm) significantly increased the activation of the serratus anterior compared to traditional push-up variations. If it's been a while since you performed traditional push-ups, it would be a good idea to start with basic variations, but elevating the feet is a viable progression if your primary goal is improved serratus function.
Another common question when performing push-ups is, "Where should my hands go?" Cogley et al. wondered this as well, and examined subjects to see how various hand positions affected EMG activity of the pecs and triceps. Researchers looked at three hand positions: shoulder width, hands together, and wide (approximately 90/90 position). The EMG for all trials showed that EMG was highest in the hands together position, which makes perfect sense — this is the position of least mechanical advantage, and therefore more musculature must be recruited to perform the movement.
Adding an unstable surface to the mix can also change which muscles are most heavily recruited. When push-ups were performed with the participant's hands on a physioball, there was a significant increase in both activation of both the triceps and rectus abdominus. It appears as though the unstable surface increases the activity of the triceps as a shoulder stabilizer, and it also increases the demands of the rectus abdominus to produce stability.
Here's where things get interesting. It seems the more weight you put on the upper extremity, the higher activation levels you get in the surrounding musculature as well. Uhl et al. examined multiple push-up positions that progressively increased loading on the upper extremity. Researchers started with patients in an all-fours position, and progressively moved them into more loaded positions such as push-up position, push-up position with feet elevated, and even single-arm push-up position.
As you can imagine, the one-arm push-up produced a significant increase in recruitment of shoulder stabilizers such as the supraspinatus, infraspinatus, and posterior deltoid over all the other conditions. It appears as though there are many ways to progressively increase the difficulty and function of the push-up, whether you're elevating the feet, performing the exercise on an unstable surface, or performing single-arm variants, we're going to give you a ton of options in the following section.
Hopefully you're starting to see that whether you're rehabbing a shoulder injury or just concerned with keeping your shoulders healthy, push-ups are an excellent and undervalued exercise. It should also be stated that just because it's a great exercise, there's also a correct way to perform it, and the basic principles of progression should be followed.
In other words, if you're rehabbing a rotator cuff injury, don't jump into the most difficult progression right away. As well, if you're a strong and healthy individual, don't mess around with the "on-knees" version — get right into something you can do correctly and that challenges you!

Performing the Push-Up

To correctly perform a push-up, lay face down on the floor with your toes pointed, hands and elbows at a 90 degree angle to the shoulders, and stomach tight. Press up to the starting position, making sure to keep the stomach tight throughout, and then lower under control to a point where the chest touches the ground. As you're lowering, tuck the elbows such that the angle between your upper arm and torso is approximately 45 degrees.
One aspect that we can't emphasize enough is to use a full range of motion. Be sure to lower under control, and at the top think of pushing your body as far away from the floor as possible. This extra "push" at the end will emphasize proper serratus function.
At this stage in the game, the powerlifters in the group are screaming, "We need more weight!" Trust us, we're all for progression; we don't want you using bodyweight resistance for the rest of your life. The easiest progression you can use in this case is a weighted vest such as an Xvest. If you need additional instruction on how to perform push-ups with an Xvest, maybe you shouldn't be lifting weights at all.

Push-Ups with Bands and Chains

That's not it though; let's look at some other ways we can perform the push-up to increase the intensity of the exercise.
Using bands is another option when we want to increase the loading of our push-ups. Again, the progression is simple — once you've mastered one band for the desired number of sets and reps, bump it up to the next level. It's that simple!
To perform push-ups with bands, you're going to take the band behind your back and place your hands in the ends of the bands such that the band is in the palm of your hand.
As you can see in the picture, you have to make an ëX' with the band. Simply twist the band, put it behind your back, and you're ready to rock!
Still not enough variation? You can also drape chains over your back.
If one chain isn't enough, either move up to the next size of chain or drape multiple chains over your back. The band and chain variations are also excellent for powerlifters looking to improve the lockout of their bench press.
We've included two variations of the chain push-up. The first version you cross the chains in a diagonal fashion over your back as in the picture above.
The behind-the-neck version is even tougher; moving the weight further up toward your shoulders will increase the activation of the rotator cuff and make the exercise a lot harder.
Finally, please note that getting the chains on your own back is a pain in the ass. Get a partner to help you out if possible.
Once you've mastered the basic push-up variations, feel free to move on to some of the following variations. They're not only great for strengthening, but they also jack-up the rotator cuff involvement and force your body to stabilize the shoulder in a more dynamic environment.

Med Ball Push-Ups

The medicine ball push-up is a great variation, as it increases activation of the rotator cuff due to the unstable surface. There are multiple variations you can use here.
Start off using a small med ball under one hand, with the other hand pushing off the ground. This will limit the instability to some degree and allow you to learn the exercise. We shouldn't have to say this, but make sure you're switching hands either in-between sets or at the midpoint of every set.
If that isn't enough challenge, move on to the double med-ball version. Place a small med ball under each hand and perform the exercise. As you increase the instability, not only will you recruit more shoulder stabilizing musculature, but you'll also force your core to increase its stiffness as well. Just try these variations with a soft-tummy; we dare you!

Blast Strap Push-Ups

The blast strap push-up is very similar to the med ball push-up, so we're not going to continue harping on the topic. Regardless, this is another effective variation you can use.

Enter the Face Pull: The Most Underrated Exercise!

The face pull may be the most underrated exercise in all of strength training. It falls into the horizontal pull category, but where rows potentially promote a downward scapular rotation syndrome and internal rotation of the shoulder joint, the face pull can do just the opposite.
Because the shoulder is either flexed or abducted 90 degrees throughout the face pull, the scapula is in upward rotation to some degree. Right away this gives us greater activation of the upward rotators, especially the upper and lower trapezius. The upward rotation offsets the pull of the downward rotators and helps prevent the development of the downward rotation dominant imbalance.
Now let's look at face pull performance. Traditionally, the face pull is performed with a rope handle or strap and a pronated grip.
In the contracted position, the pronated grip limits the degree of external rotation of the shoulder.
In thinking about movement pattern balance, we know that the internal rotators of the shoulder tend to be at least 25-33% stronger than the external rotators. We also tend to find that from a postural perspective, internal rotation of the humerus is quite common. Using the traditional pronated grip for the face pull can then potentially feed a rotation imbalance in the shoulder.
To remedy this situation, we recommend the use of a neutral grip. This allows you to pull the rope or strap past your face with the humerus in much greater external rotation and promotes shoulder rotational balance.
To further increase loading the external rotators, the lever arm can be altered by increasing the angle at the elbow. Make sure to adjust the weight accordingly; this is the second version that's shown in the above video.
Remember those short or stiff pec minors? You can make your face pull more effective by taking advantage of the acute effects of stretching the pec minor for about 20 seconds on each side. You can do this effectively by placing the front of your shoulder against a door jam and leaning your body weight forward and simultaneously pulling the scapula backward.

Diagnosis Via Face Pull

In cases where the rotator cuff is known to be weak relative to the deltoid, the posterior deltoid can overtake the rotator cuff as the primary external rotator.
This will show up in the face pull as the humerus (upper arm bone) hyperabducts relative to the scapula. In other words, as you pull horizontally, the scapula stops moving and the upper arm bone continues to be pulled back along the horizontal plane. Rather than the upper arm bone and the scapula ending up in the same plane during the contracted phase of the face pull, the upper arm bone and scapula form an angle. The dead giveaway is a dent or a dimple that forms between the posterior deltoid and the infraspinatus.
If this is the case, your shoulder program would be better served by working on some isolated strengthening to the rotator.

The Only Shrugs You Haven't Done Before!

One of the common findings in a downwardly rotated scapula is a lengthened upper trapezius. In this situation, the excessive length makes the upper trap weak and a less than effective upward rotator of the scapula. Ineffective upward rotation of the scapula, especially with overhead movements, is a recipe for rotator cuff injury.
The obvious fix would be to address the weakness with some form of shrugging movement to strengthen the upper trapezius and improve the upward rotation function. There's just one catch: the typical barbell or dumbbell shrug may make the situation worse.
A shrug with the arms at the sides will certainly activate the upper trapezius, however it also strongly recruits the levator scapulae and the rhomboids, the downward scapular rotators. This feeds the imbalance causing the downward scapular rotation dominance.
The answer is to perform a shrugging movement with the scapulae in an upwardly rotated position with the overhead shrug.
Now if you have or have had shoulder problems resulting in pain, the overhead shrug may be problematic. In this case, the next best exercise is scaption with a shrug.
Scaption is essentially a thumb-side up, dumbbell lateral raise in the plane of the scapula. The plane of the scapula is about 30 degrees or so in front of a lateral raise performed straight out to the side of the body.

Summary

Proper training and injury prevention go hand in hand. You can't have one without the other.
As you can see, we've presented one scenario where dysfunction, and potential injury, may exist that can't be "fixed" with a few sets of external rotations for the rotator cuff. A lack of attention to proper daily postures and less than optimal exercise selection can, given enough time, be a recipe for rotator cuff injury and lost training time or worse.
So what does it take to assure a healthy rotator cuff? If we had to boil it all down to three principles it would be this:

1. Maintain adequate mobility and posture of the upper back to allow for adequate mobility of the scapulae.

2. Maintain optimal balance of the muscles around the scapulae and the shoulder joint.

3. Proper exercise selection with compound movements can correct and maintain those optimal relationships that not only improve performance but also prevent injury.

Sometimes an isolation exercise like external rotations may be an answer, but that's an article for another time.

About the Authors

Bill Hartman is a physical therapist and strength and conditioning coach in Indianapolis, Indiana. You can sign-up for his upcoming Performance Training Journal at www.billhartman.net.
Mike Robertson, M.S., C.S.C.S., U.S.A.W., is the Director of Custom Athletics and President of Robertson Training Systems in Indianapolis, Indiana. Mike received his Masters in Sports Biomechanics from the Human Performance Lab at Ball State University, and has been a competitive powerlifter for the last 6 years. To contact Mike or sign-up for his free newsletter, check out his web page at http://www.RobertsonTrainingSystems.com.