Shoulder Pain And The Overhead PositionMay 02, 2023
If you are a mobility coach, CrossFit Coach, or fitness coach, and you’ve ever had to deal with a client who struggled with shoulder pain, this article is for you. In barbell sports, particularly Crossfit considering the high volume of technical gymnastic and Olympic movements, shoulder injuries and pain are so frustratingly common.
In this article, we’re going to break down the most common causes of shoulder pain, how to understand what other areas may be contributing to the pain, and what you can do to begin fixing the problem (I even throw in 6 exercises that you can start using to begin building out mobility programs for your shoulder pain clients.
But first, watch this quick intro👇
Let's dive in!
Shoulder Health And The Frequent Use Of The Overhead Position
As a mobility coach, you'll likely encounter many clients whose overhead position is tight as hell. When they press a barbell you notice some clear compensations, but sometimes it can feel impossible to help improve if you’re not quite sure what to look for or what it all means.
Common Compensations For Tight Overhead Position
Here’s a quick list of some common compensations you may notice:
- Bent elbows
- Extending through the low back
- Wrists bent/extended
- Barbell out in front of their body rather than directly overhead
- Excessive shrugging of the shoulders
- Frequently dropping/dumping the bar
“If you don’t use it, you’ll lose it”...that’s one of the most common phrases used to describe the range of motion, and with good reason. If your clients are not frequently applying particular ranges of motion (the overhead position is one that is rarely used in the everyday world), they’ll likely begin to notice some “complications” within them.
At Primal Mobility, we like to flip the script and use this as a perspective to help empower the coach and client. We prefer to say things like “spend more time in the positions you wish to improve”.
The human body is fascinating; it can and will adapt to almost anything. That being said, it’s constantly chasing efficiency. Think of it this way - if your clients are rarely using their overhead position (getting their arms overhead more often than JUST when they’re pressing or hanging from a bar)...things might start to get a little sloppy over time.
*It sounds simple as hell, but having your clients frequently apply the deep ranges of motion of the shoulder (actively bring their shoulders into deep ranges of motion rather than always having a band or bar pull them into stretched positions) is the best way to develop strength through their ranges of motion to keep the shoulders healthy for life.
Shoulder Pain And The Overhead Position
Pain is always a complex scenario, but it’s important to find ways to simplify the situation as much as possible in order to have the ability to help the situation. Physical therapy isn't the only way to relieve pain. Think of it this way, whenever considering the function of your client's shoulders, you’ll want to keep 3 main areas in mind
- The shoulders themselves
- The scapula
- The thoracic spine
Most mobility coaches will instantly go right to the source of the symptom to address the problem, but we’re different…you’re different.
Primal Takeaway: Rather than being drawn to the symptom like a moth to a flame, you know that there’s more to the situation than meets the eye.
Mobility Coaching Considerations For Clients With Pain
As a mobility coach, there are a few things you should understand well in order to have the ability to quickly help your clients when they struggle with pain in the overhead position.
- The anatomy and biomechanics of the overhead position
- The impact on your clients' bodies when they are constantly compensating (what symptoms are caused by poor overhead mechanics but are disguised as something else)
- How this all changes the mobility coaching approach
What Happens When Your Clients Lift Their Arms Overhead
As you should already know by now, the overhead position is not just a shoulder thing; it’s a spine and scapula thing too.
When a client is complaining of shoulder pain, it’s normal to be drawn to the symptom and try to solve it that way, but understanding the nuances of this position can help you solve the problem 10x faster.
Let’s break it down!
Anatomy & Biomechanics
I like to think of the human body as a bit of a puzzle. When one thing moves, another thing needs to glide into place, which often requires another thing to cooperate, and so on. With the overhead position, these additional areas that support the shoulders are the scapula and thoracic spine.
The way it works: as your client brings their shoulders into the overhead position, their scapula needs to efficiently track across the rib cage toward the thoracic spine. If the thoracic spine is restricted and can’t get into the required amount of extension, the scapula will be stopped early in its track and will limit the amount of flexion that the shoulder is able to achieve.
Below is a brief video to display how a restricted thoracic spine will cause the hands to remain far in front of the body in the overhead position.
Another way to look at it is that the shoulder simply can’t move without the scapula moving. With this perspective, we can see that anytime we’re presented with shoulder pain or weak shoulder function, we need to consider what the shoulder blade is doing and how it’s performing as well!
The Impact That The Compensations Have On The Body
When our clients are challenging their overhead position, but the position is not quite up to standard, they start to compensate, and…things start to happen.
As we broke this down above, some of the most common compensations are shrugging of the shoulders as well as extending through the lumbar spine. For this reason, neck and/or low back pain is something we may notice as a result of poor overhead ability.
Below is a brief video to display how the lumbar spine can compensate due to weak overhead mobility.
Primal Takeaway: As mobility coaches, it’s important that we find ways to understand how to read between the lines when our clients are struggling.
So What Does This Mean in Practice?
As a mobility coach, the better you understand the relationships between your joints and how that translates into movement patterns, the more successful you will be in improving performance and reducing pain for your clients.
It’s common to perceive the body as a chain - whatever happens to one link will affect another. While I do believe that the chain analogy is helpful, particularly when considering compensations, I find it more helpful to think of the body as gears to help better understand movement mechanics and patterns. When one joint moves, another area of the body is affected in some way. The way it is affected is completely dependent on its ability to move efficiently through its full potential range.
Something to consider is that if a client is struggling with the overhead position with a barbell, opening the chain by switching to dumbbells can be a very helpful way to reduce the level of unnecessary stress being placed in their body through poor mobility and instead offer a more “forgiving” movement path that allows them to move around their limitations in range of motion. This certainly doesn’t have to be a permanent substitution, but can offer some freedom for the shoulders while you work to offer a long-term solution to their mobility problems!
Primal Takeaway: Think of the body as gears–when one joint moves, another area of the body is affected in some way. How it is affected is completely dependent on its ability to move efficiently through its full potential range.
Two Common Causes Of Overhead Shoulder Pain
The shoulders are the joint in our body that holds the most range of motion potential. If you have a look at the anatomy of the glenohumeral joint, you’ll notice how shallow it is. It’s barely being held together by much at all. This is where the significant ROM potential stems from - there are hardly any bony structures getting in the way to impede movement; it’s simply being held together by soft tissue.
While the high-level ROM is definitely a positive attribute, with that incredible freedom comes a higher risk of potential injury and/or pain as well. Shoulder pain is common in every sport, but particularly in Crossfit due to the high volume and the technical patterns required to accomplish the gymnastic and Olympic movements.
The two most common causes of shoulder pain in the overhead position are:
- Rotator Cuff Weakness (particularly external rotation)
- Restriction in the thoracic spine causes the shoulders to compensate while in the overhead position
1. Rotator Cuff Weakness
Rotation is a highly important mechanic of the shoulders during Olympic lifts and bar gymnastic movements, particularly external rotation. Without mentioning the obviously poor overhead position, a common issue that is noticed in the average CrossFitter/Olympic weightlifter is an awful front rack position as well. This is where most people will start to complain that they have poor wrist mobility due to the pain they feel within the position. Again, this is why we carry a root cause perspective because it’s often not the wrists at all that is the issue but poor shoulder external rotation. If the shoulders were able to rotate more, they would be able to keep the elbows higher, and, as their mobility coach, you’d notice much less stress being placed at their wrists (photo below to show what I’m talking about here).
Another common ROM restriction that is noticed is a poor overhead position in general (we’ve all seen those bent elbows at the top of a jerk that makes us cringe). While many mobility coaches will fairly assume that the lats are the cause of overhead restriction, weakness in shoulder external rotation also plays a large role in this (which can also be limited by restriction in the lats!). See, as the arms move toward the “locked out” overhead position, the humerus will naturally rotate externally within the glenoid fossa. This means that without sufficient external rotation, the overhead position is not happening.
Common issues caused by poor shoulder rotation:
- Poor front rack position
- Restricted overhead position
- Inability to get deep shoulder flexion during kipping pattern
- Inability to perform the catching position in muscle ups
How to Fix the Issue
In order to solve the rotator cuff weakness we must first identify which function is most urgent. While both internal and external rotation is clearly important mechanics of the shoulder, we will want to find out which needs our attention most.
Next, we will want to keep in mind that the rotator cuff is a group of small muscles that are barraged in Crossfit with high volume. This means that they take on a lot of stress, and we will want to remain conscious of that fact - they will likely fatigue relatively quickly. With all of this in mind, our approach needs to be progressive and strength-focused. While stretching is definitely a helpful component of how you should be targeting the rotator cuff to help your clients overcome their issues, what they really need is strength.
Start by making sure the protocol that you put together begins with some stretching and then guides them into an active approach that trains their nervous system to hold onto the deep ranges of motion. In order to do this we will need to build control and strength within their ranges.
Mobility Exercises For Shoulder External Rotation
Here are 3 active, strength/control-based exercises you can start playing around with and implementing in a progressive protocol to help your clients with this issue:
2. Restriction In The Thoracic Spine
The thoracic spine is such an important component of shoulder function in general. While most mobility coaches know this, they lack the understanding of why - which is also very important if you want to understand how to effectively approach the situation.
It’s worth reiterating here that the shoulders rely on the thoracic spine to have efficient movement. As we start to move our shoulders in any capacity, but particularly when lifting them into the overhead position, our scapula will begin to track across the rib cage in multiple possible directions. As they do so, they will often track toward the thoracic, causing a need for sufficient extension from that area of the spine.
Without the required range of motion from the thoracic spine, the scapula will be stopped early in its track and will subsequently stop the shoulders early in their movement as well.
Common issues caused by poor thoracic extension
- Restricted overhead position
- Poor front rack ability
- Inability to get deep shoulder flexion during kipping pattern
- Forward head position causing neck discomfort
- Compensations through the lumbar spine (often when getting a bar overhead) that causes low back pain
- Bent elbows when trying to lock out the bar in the overhead position
How to Fix the Issue
Unfortunately, the thoracic spine is an area that is commonly restricted, so regardless of who you’re working with, their thoracic likely needs some attention to solve and help prevent issues. That being said, especially for those that have to sit all day for work (desk jockeys), the thoracic will spend a lot of time in flexion, which can make it challenging to see progress quickly.
Just like any other area, you’ll want to approach the thoracic in a progressive manner by first meeting the client where they’re at. This likely means that you will often have to start off in a very passive manner with lots of stretching and then slowly build toward strength and control-based work.
Considering that the thoracic spine spends a lot of time in flexion (I’m just assuming that your clients are most commonly desk workers, or at least sit for over 6+ hours per day - as most people do these days), a powerful approach to your mobility coaching will be to find ways to help your clients find ways to break certain habits that keep them sitting for long periods of time.
Tips To Help Clients Be More Active
- Get them aiming for more steps in a day to help their hips and spine get more movement
- Have them stand up from the seated position every hour at a minimum (have them move around and stretch a bit when they get up - this goes a long way)
- Help them drink more water throughout the day (they will have to get up to pee more frequently, which breaks the sitting time up)
Mobility Exercises For The Thoracic Spine
Here are 3 exercises you can use to start playing around with your clients’ protocol to improve their thoracic function
Use It Or Lose It
It sounds cheesy, but when it comes to mobility it’s true. If you don’t use it, you lose it. Our range of motion is dictated by our nervous system through the stretch reflex. When our muscles stretch, they will trigger a reaction from the muscle spindles, which are tiny little stretch receptors within the muscle itself. Once those spindles are triggered, they send a message up to the spinal cord to suggest to the nervous system that we’re approaching deep ranges of motion that we don’t yet have control over - thus making them more dangerous and causing a higher likelihood of injury.
As a result, our nervous system will prompt an automatic contraction of the muscle to avoid any further stretching from happening in an effort to protect us from potential injury. For this reason, our range of motion is governed by the current excitability of the stretch reflex.
As we use our deep ranges of motion more frequently and consistently, our nervous system will begin to trust that we can handle them and that we are, in fact, safe to use them. At this point, the muscle spindles will begin to get triggered later on in the stretch process and “grant access” to deeper ranges of motion as a result.
The trick truly is to get your clients into their weak ranges of motion more frequently. It’s very challenging work, especially if you’re having them do it actively, but it will improve their mobility and reduce their pain.
Primal Takeaway: Have your clients spend more time in the positions they wish to improve.
In this article, we talked a lot about what areas are problematic and how you should approach them. However, we have yet to touch on what should be avoided.
The answer; is not much, really. Just because something is causing your clients pain doesn’t necessarily mean that you need to take an exercise (or position) away from them entirely. Rather, what we need to do is find the appropriate entry point and build up from there.
While substituting an exercise is a great way to avoid triggering and aggravating the pain in the short term and long term, we want to reintroduce that pattern/exercise in a pain-free way while we continue to improve their mobility weaknesses to help avoid a relapse of the issue.
4 Programming Tips For Pain
Here are 4 programming tips to help you navigate your clients' pain in a progressive way:
- Add more tempo: This can help your client develop better control of the pattern and begin to grow their awareness of the currently triggering ranges of motion.
- Reduce the load: Taking off some of the weight will offer more control of the pattern, similar to why we may want to introduce tempo, as well as reducing some additional stress to the areas that need some space to recover
- Substitute for another exercise: This does not mean we need to ditch the pattern entirely. If handstand pushups are causing discomfort, try substituting for a push press or a strict press variation. If squats are problematic, try substituting for Bulgarian split squats (I’m sure your client will appreciate that). The idea is to try to maintain the pattern while playing around with exercise selection to find something more suitable while you work on improving the weaknesses that are causing the pain.
- Reduce the volume: If all the other suggestions aren’t helping reduce the unnecessary stress placed on the problem area, perhaps the discomfort and/or pain stemming from a technical breakdown of the pattern through the onset of fatigue. Try reducing the total volume to help your client keep technically sound movement patterns.
Mobility Coaching For Clients Who Suffer From Pain
Really, what it all comes down to is keeping your clients feeling great and happy to keep coming back for more. As their mobility coach, your job is to find ways to help them remain consistent so they can continue to improve their health and longevity over time. This is why we focus on a progressive protocol through your mobility programs, as well as finding ways to help them navigate their workouts in the meantime.
I see you. You’re a badass coach that wants to be the best at what you do. You want to solve problems for your clients and understand what mobility issues are getting in the way of their performance and overall strength.
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