The shoulder is a complex ball and socket joint that can be prone to injury due to its unstable nature involving a shallow socket (glenoid fossa) and large contact point being the humeral head. As a result, the shoulder relies heavily on the surrounding muscles and ligaments for most of its stability. Athletes involved in overhead contact sports are more at risk of shoulder injuries, particularly if they have weakness around the shoulder, poor technique or training errors. Recurrence rates for shoulder injury is up to 75% in overhead contact sports, emphasising the importance of targeted and complete rehabilitation. Chronic shoulder pain in this population group often develops from sport specific adaptations over time creating alterations in strength, balance and control around the shoulder joint.

In this blog I discuss the main causes of shoulder pain in the overhead athlete but also acknowledge that shoulder pain is not unique to overhead athletes but is common to many in the sport and fitness industry. Whether you are a cricket player or an extreme gym goer, shoulder problems interfere with many in reaching their fitness goals. Shoulder injuries are a major concern within the crossfit population and strength training related injuries that commonly present to physiotherapists.

What contributes to shoulder pain in this population group?

Rapid increase in training volume / loads or intensity
Increased or decreased external rotation range of movement (particularly throwers)
Faulty mechanics
Training errors (unbalanced strength development)
Reduced scapulothoracic range of movement
Weakness or tightness of the rotator cuff muscles
Hyper or hypomobility of the shoulder joint
Inefficient whole body movement patterns

Common acute sporting shoulder injuries include:

Dislocation / subluxation
AC joint injury
Labral tear
Rotator cuff tear
Long head biceps tear

Common chronic sporting shoulder injuries include:

Overload
Subacromial impingement
Tendonopathy
Rotator cuff insufficiency / tear

Why is the rotator cuff so important?

The rotator cuff muscles act as a primary stabilizer of the glenohumeral joint which functions together to set the humeral head into the shallow socket (glenoid). In higher level sporting shoulders efficiency of the rotator cuff is even more important.

Due to the high recurrence rate of shoulder injuries, training and rehabilitation needs to target consistent efficiency of the rotator cuff. Repetitive overhead loading can quickly fatigue the cuff, reducing stability and resulting in pain. These muscles need to engage to ensure the humeral head remains stable throughout movement and training should in turn, ensure the cuff is constantly being switched on.

We need to get stability of the rotator cuff before addressing strength

If the cuff doesn’t switch on and do it’s stability role, increasing the load and heavier resistance training is only going to create problems due to muscle imbalances, likely resulting in pain. In the athletic population, incorporating some rotator cuff activation exercises prior to the strengthening program or sport can provide the best chance of protecting the cuff. This allows the shoulder to tolerate higher demands and protect against injury. If the rotator cuff doesn’t work adequately to keep the ball and socket joint centred the humeral head moves excessively creating irritation on other structures around the joint.

The body often takes the path of least resistance

If there’s a weakness of the stabilisers around the shoulder, often compensations occur where the larger muscle groups take over to assist the movement. This can be highly detrimental to shoulder function and create a further imbalance. This is often seen with training and loading errors. The brain begins to forget certain movements because they feel too hard and often takes the easiest route. It feels easier to use stronger muscles and gradually the movements they generate dominate.

Gym based rehabilitation

Many shoulder injuries can develop from incorrect training load and poor technique with strengthening exercises at the gym. A major muscle imbalance can manifest around the shoulder from these errors. Upper body resistance training exercises often target large muscle groups for strength and muscle building purposes while the small stabilizers are often neglected.

“If it only hurts in the shoulder when lifting a bar with 100kg of iron, does that really mean you can ignore it (as many do)?”

Common compensations in this population group:

Repetitive downward force of the top of the shoulder onto the ball and socket joint is extremely destructive which is a result of muscle imbalance - ‘downward rotators’ (pec minor, levator scap, rhomboids) dominate ‘upward rotators’ (serratus anterior, middle and lower trapezius) resulting in poor shoulder blade control ‘scapula winging’.

→ In short, any simple push-pull exercise at the gym may cause too much downward force into the crucial structures of the shoulder, most commonly being the supraspinatus tendon. Tearing and impingement of these tendons accounts for many painful shoulders in the gym.

Dominant anterior chain - gym goers targeting excessive chest exercises (push ups, bench press, pec fly etc), in turn upper back muscles become weak and lengthened. Dominant pecs, lat dorsi and upper traps.

→ Rounded shoulder and upper back appearance impacting on range of movement and muscle activation.

Incorporating the whole kinetic chain into shoulder rehabilitation

Overhead athletes not only need to target specific shoulder based rehabilitation, but need to consider the impact of the entire system on shoulder function. Upper limb injury risk is higher in the subsequent years in overhead athletes following injury to the lower limb which identifies the need of involving the lower limb and kinetic chain in rehabilitation. Incorporating the rest of the body can help achieve efficient force transfer through the system. Training that adopts this strategy ensuring efficiency through legs and trunk, immediately unloads the shoulder. Sports people require efficient movement patterns through the whole kinetic chain for optimal function and the rotator cuff has to be able to withstand multidirectional load, (e.g, the overhead thrower requires shoulder range of movement and control, thoracic rotation, trunk stability, lower quadrant control and ankle stability).

Force production through the kinetic chain in overhead athletes

50% lower quadrant
30% trunk
20% shoulder

A warm up drill that reinforces the movement pattern and switches on the cuff is a good way to optimise function which will be demonstrated in videos to come. While ongoing shoulder problems are a common concern in this population, management should involve a modification of the training program and guided physiotherapy.

Remember, one size does not fit all!! So if you’re concerned or unsure about whether your training or strength program is suitable, your physio can help guide you!

Happy training :)

The sporting shoulder