© National Strength & Conditioning Association

Volume 23, Number 5, pages 10–18

Avoiding Shoulder Injury

From Resistance Training
Chris J. Durall, MS, PT, SCS, ATC, CSCS
Physical Therapy Program
Creighton University

Robert C. Manske, MPT, CSCS

Physical Therapy Program
Wichita State University

George J. Davies, MEd, PT, SCS, ATC, CSCS

Physical Therapy Program
University of Wisconsin-La Crosse

Keywords: shoulder; injury; impingement; instability.

ONE OF THE PRIMARY RESPON- instability (19, 21), or impinge- result of a congenital hypermobil-
sibilities of the personal trainer or ment (8, 9, 12, 16). ity, a traumatic injury, or a grad-
strength and conditioning special- In this article we will identify ual loosening of the ligamentous-
ist is educating clients in proper shoulder exercises commonly per- capsular restraints (19, 21).
exercise techniques. More impor- formed in fitness centers that may Repeated stretching of ligamen-
tantly, however, the strength and contribute to or exacerbate gleno- tous-capsular restraints increases
conditioning professional must be humeral joint injury. Alternative the likelihood of permanent elon-
able to design exercise programs exercises that may be substituted gation (acquired ligamentous laxi-
that are appropriate and safe for will be described along with the ra- ty) and injury (10, 21). If a liga-
each client. Because there is a tionale for the variations. It is be- ment or capsule is loosened
wide range of exercises to choose yond the scope of this article to pre- significantly, surgery may be nec-
from when targeting specific mus- sent an exhaustive review of essary to restore stability. Joint
cles or muscle groups, it is sensi- contraindicated exercises for all hyperlaxity involves excessive mo-
ble to avoid exercises that are known shoulder pathologies; bility without the presence of pain,
more likely to lead to injury. rather, glenohumeral joint patholo- whereas painful and uncontrol-
Injuries to the shoulder are gies commonly associated with re- lable excessive joint movement
relatively common among weight sistance exercises will be dis- characterizes joint instability (21).
trainers and can be career-threat- cussed. Avoiding risky exercises When the static glenohumeral lig-
ening to those at the competitive helps prevent injury in healthy amentous-capsular restraints are
level (14, 26). Fortunately, most clients and further tissue damage excessively lax or unstable, the dy-
shoulder injuries from resistance in clients recovering from injury. namic rotator cuff muscles are
training are minor musculo-ten- thought to exert greater force to
donous strains or ligamentous- ■ Glenohumeral Instability stabilize the humeral head (10).
capsular sprains. However, when The glenohumeral joint is very mo- This dynamic compensation often
improper exercises or exercise bile but lacks bony congruency, results in fatigue followed by rota-
techniques are utilized, resistance rendering it vulnerable to exces- tor cuff tendonitis and pain. Sen-
training may exacerbate or con- sive laxity (hyperlaxity) or instabil- sibly, exercises that impart signif-
tribute to the development of ity. Glenohumeral joint hyperlaxi- icant stresses to the glenohumeral
glenohumeral joint hyperlaxity, ty or instability may occur as the ligamentous-capsular restraints

10 Strength and Conditioning Journal October 2001

 zontal abduction (Figure 1) maxi- 2). This modification assures that
mally stresses the anterior cap- the shoulders will avoid the at-risk
sule (6, 17–19), this movement position throughout the lift.
combination should be avoided Another exercise usually per-
during resistance exercises in in- formed with the weight positioned
dividuals with anterior hyperlaxi- behind the neck is the back squat.
ty or instability. Examples of com- During the back squat the shoul-
mon exercises that put the der is maintained in an externally
glenohumeral joint in the “at-risk” rotated, abducted, and horizontal-
(6) position (external rotation com- ly abducted position. Clients with
bined with abduction and hori- glenohumeral anterior hyperlaxity
zontal abduction) include the or instability should be instructed
latissimus pull-down performed to either use a modified center of
behind the neck, the shoulder mass bar (13) or perform a front
press performed behind the neck, squat instead. The elbows are po-
the wide-grip bench press, and the sitioned anterior to the shoulder
pectoralis fly. when using a modified center of
Exercises commonly per- mass bar (13) or performing a
formed behind the neck (e.g., front squat, substantially decreas-
shoulder press and latissimus ing anterior glenohumeral liga-
pull-down) should be performed ment stress. If front squats are
with the elbows approximately 30º performed, we recommend using
anterior to the shoulder in the a self-spotting rack (e.g., Smith
plane of the scapula (scaption) to rack) to prevent injury if there is a
decrease stress to the anterior loss of control of the weight.
glenohumeral joint capsule (21). The wide-grip flat bench press
The combination of shoulder ex- (barbells or dumbbells) or the
ternal rotation, abduction, hori- seated machine chest press
zontal abduction, and excessive should be modified to avoid exces-
cervical spine flexion during the sive horizontal abduction. Cases
behind the neck latissimus pull- of bilateral anterior shoulder dis-
down was blamed for 1 reported location during bench pressing
case of temporary arm paralysis have been reported as a result of
from brachial plexus injury (23). the horizontal abduction stress on
The latissimus anterior pull-down the anterior glenohumeral liga-
to the chest can be substituted to ments combined with heavy resis-
train the latissimus dorsi, rhom- tance (1, 11). Excessive horizontal
boids, and elbow flexors without abduction during the bench press
Figure 1. Arm (humeral) external rota- compromising the anterior gleno- can be avoided by limiting hand
tion combined with horizon- humeral joint. spacing to 1.5 times the shoulder
tal abduction.
Overhead (military) shoulder width (7), placing a cushion or roll
presses are typically performed on the chest, or using a range of
should be avoided, particularly if
behind the neck, placing the motion (ROM) limiting stop on a
preexisting instability or hyperlax-
shoulders in the at-risk position. machine or self-spotting rack.
ity is present.
Performing the shoulder press Likewise, limiting hand spacing
Anterior Glenohumeral Instability with the hands and elbows anteri- and horizontal abduction on a
or to the shoulder is preferable chest press machine protects the
The anterior glenohumeral joint
whether using a bar (preferably anterior glenohumeral capsulo-
capsule is the most common site
with a spotting rack), dumbbells, ligamentous restraints. Clients
of hyperlaxity and instability in
or a machine. In our clinic, pa- with hyperlaxity or instability
the shoulder (4). Since shoulder
tients are instructed to face back- should approach the weighted bar
(humeral) external rotation com-
ward on the seat when using the incline press exercise with caution
bined with abduction and hori-
shoulder press machine (Figure as the arms are maintained in the

October 2001 Strength and Conditioning Journal 11

at-risk position throughout the
entire movement (5). Alternatively,
dumbbells may be employed dur-
ing the incline press with careful
avoidance of the at-risk position.
Conversely, throughout the entire
movement of a decline press, the
arms are maintained in a safe po-
sition below 90º flexion and 45º
abduction with minimal external
rotation making this a reasonably
safe pectoral strengthening exer-
cise with a weighted bar or dumb-
bells.
Like the bench press, hand
spacing during push-ups should
also be limited to reduce horizon-
tal abduction. An alternative tech-
nique for performing a push-up
using a standard weight bench is
demonstrated in Figure 3. This ex-
ercise can be performed from a
kneeling or standard push-up po-
sition. In addition to reduced
stress on the anterior gleno-
humeral ligaments due to the nar-
rowed grip and decline movement,
our clients have reported less
wrist discomfort with this push-
up technique compared with the
standard push-up technique per-
formed on the floor.
Another common strengthen-
ing exercise for the anterior shoul-
der and chest musculature is the
pectoralis fly. Excessive horizontal
abduction should be avoided
when performing this exercise in
order to minimize anterior capsu-
lar distention. This can be accom-
plished by instructing clients to
initiate the movement with their
elbows slightly in front of their
shoulders (scapular plane) and to
maintain their elbows below
shoulder level throughout the Figure 2. Military press performed anterior to the shoulder.
movement. The elbows should be
kept below shoulder level to re- chine before attempting the move- glenohumeral joint capsular hyper-
duce shear across the subacromi- ment with free weights. laxity or instability. Although the
al space, which may irritate the Stretching the pectorals with purpose is to stretch the pectoralis
rotator cuff tendons and bursa. the arm horizontally extended and muscle, the noncontractile anteri-
Clients may need to practice this externally rotated should be avoid- or capsule is also stretched with
technique on a pectoralis fly ma- ed in individuals with anterior the arm in horizontal abduction

12 Strength and Conditioning Journal October 2001

Figure 3. Alternative push-up technique using standard weight bench.

and external rotation. An alterna- posteriorly unstable shoulder may

tive technique for pectoral stretch- need to be avoided entirely. The
ing is illustrated in Figure 4. This cross-chest stretch should be
stretch primarily affects the pec- avoided if a posterior instability is
toralis minor; however, the pec- present. In addition, rowing exer-
toralis major will also receive a mild cises should be modified to reduce
stretch when performed properly. the amount of arm distraction
during the eccentric phase of the
Posterior Glenohumeral Instability row. Clients can be instructed to
Just as stretching the anterior begin and finish the rowing move-
glenohumeral joint capsule may ment with their elbows slightly
exacerbate an anterior instability, bent to reduce posterior capsular
stretching the posterior capsule stretching. Deadlifts and power
may exacerbate a posterior gleno- cleans might also need to be Figure 4. Pectoralis stretching tech-
humeral instability. The posterior avoided or modified if a posterior nique for clients with ante-
glenohumeral joint capsule is instability is present. Both of rior glenohumeral hyperlax-
ity or instability. (a) Rest
stressed when weight is borne these exercises stress the posteri- shoulder to be stretched
through the arm with the shoul- or capsular restraints as the arm against corner of wall using
der flexed (e.g., narrow-grip bench is pulled forward when attempting towel cushion. (b) Initiate
stretch by squeezing (re-
press or push-up), or when the to lift or lower the weight from the tract) shoulder blades
flexed shoulder is pulled forward floor. The deadlift might need to be (scapulae). (c) Greater
(e.g., eccentric phase of rowing ex- avoided entirely; however, the stretch may be obtained by
using the opposite hand to
ercise) or across the chest (18, 21, hang clean can be substituted for pull the pectoral muscles
24). Obviously, strengthening and the power clean, eliminating the toward the midline of the
stretching exercises that stress a pull from the floor. body.

October 2001 Strength and Conditioning Journal 13

 Hand placement should be ad-
justed when attempting to per-
form the bench press or push-up
in the presence of a posterior in-
stability. In contrast to the narrow
grip recommended during the
bench press or push-up for shoul-
ders with anterior instabilities, in-
dividuals with a posterior instabil-
ity should use a wider grip to
disperse direct force through the
arm and into the glenoid fossa.

■ Subacromial Impingement
Primary Impingement Syndrome
Repeated compression of the rota-
tor cuff tendons and bursa against
the overlying acromion and/or
coracoacromial ligament may lead
to irritation and inflammation.
When the cuff tendons and/or
bursa are inflamed, the subacro-
mial space is further diminished
and the tendons and bursa are
often impinged (pinched) in the
subacromial space—a condition
known as primary subacromial
impingement (16). Individuals
with a primary impingement often
experience pain when lifting their
affected arm (particularly above
shoulder level) because of com-
pression of the inflamed and sen-
sitized cuff tendons and bursa.
Several resistance exercises
should be modified to prevent in-
ducing or exacerbating a primary
impingement.
The lateral raise, an excellent
exercise to strengthen the middle
deltoid and supraspinatus, is
commonly performed with the
palm facing down (internal rota- Figure 5. Lateral raise on machine with concomitant humeral internal rotation.
tion of the glenohumeral joint),
which can lead to rotator cuff im- ity of the humerus pinches the ro- with the arms externally rotated.
pingement (Figure 5). During ele- tator cuff tendons and bursa Clients should be instructed to
vation of the arm, the rotator cuff against the acromion (8). Repeti- use a neutral grip done by point-
tendons normally move with min- tive pinching can lead to inflam- ing their thumbs toward the ceil-
imal compression beneath the mation and damage of the rotator ing to promote arm external rota-
overhanging acromion. If the arm cuff tendons or bursa (16). To tion (Figure 6). Seated lateral raise
is internally rotated during eleva- minimize compression, elevation machines that require elevation
tion, however, the greater tuberos- exercises should be performed with concomitant internal rotation

14 Strength and Conditioning Journal October 2001

should be avoided (Figure 5). Lat-
eral raises with the arm external-
ly rotated using dumbbells may be
substituted.
Another exercise that may
lead to subacromial impingement
is the upright row. During this
exercise the arm is maintained in
an internally rotated position
throughout the full range of eleva-
tion. We recommend either avoid-
ing this exercise entirely or limit-
ing elevation to 80º and keeping
the elbows lower than the shoul-
ders to avoid rotator cuff impinge-
ment.
Subacromial impingement can
also be exacerbated by exercises
that involve excessive flexion (16).
The pullover exercise performed
supine with free weights (Figure 7)
or on a machine forces the rotator
cuff tendons and bursa against
the undersurface of the acromion
when the arms are hyperflexed.
This exercise can be made safer by
simply limiting flexion to the nor-
mal physiological limits or a com-
fortable ROM. Alternatively, latis-
simus pull-downs performed in
front of the body, which challenge
identical muscle groups, may be
substituted.

Secondary
Impingement Syndrome
Exercises that contribute to hy-
perlaxity of the anterior gleno-
humeral joint (discussed previ-
ously) can also contribute to the
development of a secondary rota-
tor cuff impingement (10, 12). If Figure 6. Scaption–lateral raise in the scapular plane (30º anterior to the frontal
the arm does not remain centered plane).
in its shallow fossa during move-
ment, the rotator cuff tendons
and bursa can be repetitively ment. This condition is referred to ercises that combine arm external
compressed and become in- as a secondary impingement (10, rotation with horizontal abduc-
flamed. In addition, the rotator 12) because the impingement de- tion. Therefore, the modifications
cuff muscles must work harder in velops secondary to hyperlaxity or for anterior shoulder instability or
an attempt to restore stability and instability. With secondary im- hyperlaxity should be followed
become prone to fatigue, ten- pingement it is sensible to avoid when prescribing exercises for an
donitis (microtrauma), inflamma- repeated stress to the anterior individual with a secondary im-
tion, and subsequent impinge- capsular restraints by limiting ex- pingement.

October 2001 Strength and Conditioning Journal 15

Internal Impingement Syndrome
Internal impingement of the artic-
ular side of the supraspinatus and
infraspinatus tendons against the
posterior glenoid labrum may
occur when the shoulder is in the
at-risk position (Figure 1; 3, 9).
This form of impingement is most
prevalent in throwing athletes be-
cause of repetitious shoulder ex-
ternal rotation combined with ab-
duction and horizontal abduction,
which can impinge the tendons
against the labrum. Anterior
glenohumeral instability may be a
contributing factor to the develop-
ment of internal impingement (2,
10). Sensibly, exercises that in-
duce posterior glenohumeral joint
impingement pain (not muscle Figure 7. Pullover exercise performed supine.
soreness) and/or exacerbate an
anterior instability should be
avoided. Performing shoulder ex-
ercises out of the at-risk position
is recommended.

■ Recommended
Shoulder Exercises
Weight trainers frequently develop
the larger shoulder muscle groups
(i.e., pectorals and deltoids), yet
often fail to develop the smaller ro-
tator cuff and scapular stabilizers.
This pattern of weakness and
asynchronism in the smaller
shoulder muscle groups was
found to occur in a group of
weight trainers who were unable
to continue lifting because of
shoulder pain (6). We recommend
that exercises that develop all of
the muscle groups about the
shoulder, not just the larger mus-
cles, be provided to clients. In our
clinic, most patients with shoulder
dysfunction perform exercises de-
scribed by Moseley et al. (15),
Townsend et al. (25), and Davies
(3). This combination of exercises
(scaption [Figure 6], rowing, push-
up with a plus, press-up [Figure
8], and horizontal abduction with Figure 8. Press-up performed on a standard weight bench.

16 Strength and Conditioning Journal October 2001

external rotation) was shown to
elicit high levels of electromyo-
gram (EMG) activity in all of the
shoulder muscles. Internal and
external rotation exercises in neu-
tral or at 90º abduction (Figure 9)
are also commonly prescribed for
patients with shoulder dysfunc-
tion (3). Overhead athletes need to
develop strength in the intrinsic
rotator cuff muscles to steer the
humeral head in an inferior direc-
tion while the arm is elevated. In-
adequate strength can lead to ex-
cessive humeral head elevation
and subsequent impingement of
the soft tissues beneath the
acromion (22).
As with any unfamiliar exer-
cise techniques, we encourage you
Figure 9. Humeral external rotation at 90º abduction using a cable column.
to practice the exercises described
above before instructing clients.
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Durall Manske Davies

Chris J. Durall, MS, PT, ATC, Robert C. Manske, MPT, CSCS, George J. Davies, MEd, PT, SCS,
CSCS, is an assistant professor in is an assistant professor in the ATC, CSCS, is a professor in the
the Physical Therapy Program at Physical Therapy Program at Wi- Physical Therapy Program at the
Creighton University in Omaha, chita State University and is a University of Wisconsin-LaCrosse
NE and is a physical therapist at physical therapist at Via Christi in LaCrosse, WI, and director of
St. Joseph Hospital at Creighton Orthopedic and Sports Medicine Clinical Research Services at Gun-
Medical Center in Omaha, NE. in Wichita, KS. dersen Lutheran Sports Medicine
in Onalaska, WI.

18 Strength and Conditioning Journal October 2001