Training Young Athletes With Shoulder Injuries

Just when you think there is no way athletes can break current records, they do—and the athletes doing so get younger and younger. At one time NBA draft picks who had yet to finish college grabbed all the headlines, but now teenage players like LeBron James sell out college and pro arenas across the country and sign larger contracts than Michael Jordan!

The pressures on high school and collegiate athletes are escalating and the competitive bar is constantly being raised. Each year the demands on physicality and mental toughness are greater than the year before. For athletes who want to compete at the highest levels, training in the off-season is not only commonplace but essential. High expectations for playoff berths, college scholarships and individual records come from coaches, parents, teammates, athletic directors and the athletes themselves.

But all the dreams of success and glory can evaporate if an athlete is taken out of the lineup due to injury. While injured athletes rest, their competitors make gains on the field and in the weight room, deconditioning sets in, and confidence erodes.

Although any injury will most likely be addressed by the athlete’s team athletic trainer and/or a physical therapist—who will focus on decreasing the stress on the affected tissue and preventing reinjury—a personal trainer who is experienced in finding safe ways to continue training can also be a vital component in the athlete’s recovery.

Here we will take a look at shoulder injuries, which are particularly distressing to athletes who participate in sports that require strong overhead motions, such as baseball, softball, volleyball, basketball and swimming. What are the ramifications in the training room? Which exercises should be avoided, and which can be modified to keep the athlete conditioned while avoiding further injury?

Common Shoulder Injuries

The shoulder is a complicated area in which many articulations work together to create one mobile yet stable joint. (See the Fine Anatomy column on page 36 in the October 2003 issue of IDEA Personal Trainer for more details on shoulder anatomy.) The glenohumeral joint is where the humeral head (ball) meets the glenoid fossa (socket). The glenoid fossa is a rather shallow area; a fibrocartilage ring called the glenoid labrum is attached to its rim to help deepen the fossa and improve stability. In addition, the shoulder joint is completely surrounded by a loose bag of tissue—a capsular envelope that also contributes to stability.

To understand the multidirectional, ever-changing movements of the humeral head, it’s helpful to visualize a seal struggling to balance a ball on its nose. This visual demonstrates the need for the muscles, ligaments, tendons and joint capsule surrounding the shoulder to provide a solid stabilizing unit.

The structure of the shoulder joint opens itself up to a myriad of possible injuries, including anterior and posterior instability, impingement and glenoid labrum damage. There are a number of things a personal trainer can do to help clients with these injuries continue training safely. Researchers cited in The American Journal of Sports Medicine found that modifying hand spacing, grip, and start and finish positions during certain exercises could work to reduce strain on the injured shoulder (Fees et al. 1998).

As a general rule, exercise progression will depend on the original injury. Shoulder muscles should be warm, loose and stretched before weight training. Warming up on an upper-body ergometer or similar machine will usually make clients with a history of shoulder injury feel better while performing their upper-body weightlifting routine.

Anterior Instability

As explained above, the glenoid fossa is a rather shallow area, and instability can be an issue. More stability is provided if the humeral head is compressed into the fossa during humeral head translation. Com-pressive forces come from the rotator cuff, the joint capsule and surrounding ligaments, and the long head of the biceps. Failure of any of these mechanisms can result in glenohumeral instability. Problems with the positions of abduction and external rotation suggest an anterior instability, the most common type. Anterior instability at the shoulder can be due to a single-event trauma (i.e., a dislocation), repetitive trauma, a tendency for a loose joint capsule and ligaments, or a capsular tear (Hertling & Kessler 1996). For athletes who experience recurrent, painful episodes of dislocation, surgery may be required to stabilize the shoulder joint.

Individuals with anterior instability should avoid stress and uncontrolled stretching to the anterior (front) structures of the shoulder. Shoulder abduction and external rotation should never be forced. Exercises that tend to place the shoulder in the provocative “high-five” position should be avoided (Fees et al. 1998). Rick Burkholder, head athletic trainer of the Philadelphia Eagles, advises, “I never allow our athletes to do behind-the-neck pull-downs or presses. I think [these movements are] too stressful on the anterior capsule, and the rewards are not worth the risk.”

With an anterior instability, compression of the joint surfaces is very important during shoulder movement. Compression helps place the humeral head in the glenoid fossa, thereby preventing excessive translation. Balanced strength between the rotator cuff and scapular musculature plays a critical role in positioning the glenoid fossa at an appropriate angle to create an ideal meeting point for the humeral head.

See “Considerations With Anterior Instability” for specific exercises to avoid when training clients with this condition.

Modifications. To decrease the
likelihood of reinjury, some exercise modifications are necessary. For example, rowing movements should be done with a grip that places the glenohumeral joint in internal rotation; and lat pull-downs should be performed anterior to the chest instead of posterior (Einhorn 1985). Using the Smith machine or power rack with shoulder press activities will control the vertical displacement of the bar and diminish uncontrolled horizontal movements. As an alternative, the anterior deltoids could be worked using dumbbell front raises—thus avoiding shoulder presses altogether.

Bar squats can be adapted in one of two ways: by placing the bar in front of the body and securing it with arms crossed in front of the chest, or by using a center-of-mass bar.

Bench presses should alternate between the flat and decline bench. Whether the shoulder joint capsule is torn or just very loose, handoffs should be performed with all bench press activities. Coupling these modifications with a change in grip width should help decrease the stress on the anterior glenohumeral structures. A narrower grip of 1.5 times the biacromial width will decrease the total amount of shoulder abduction to less than 45 degrees, and shoulder extension to less than 15 degrees (Fees et al. 1998). These changes will alter the start and finish positions, and the bar will touch higher on the chest wall.

Posterior Instability

Glenohumeral posterior instability, which is less common than anterior instability, may be associated with trauma incurred when an athlete’s shoulder is in a forward-flexed, internally rotated position. For example, in football, when an offensive lineman blocks another player, the lineman’s arm is flexed forward to 90 degrees, his elbow is fully extended and the humeral head of his shoulder is driven to the posterior as he performs a pushing maneuver (Wilk, Andrews & Arrigo 1997).

During weightlifting, problematic positions will likely occur with exercises that reach across the body. (Einhorn 1985). See “Considerations With Posterior Instability” for exercises to avoid with this condition.

Modifications. When performing bench presses, the athlete’s hands should be spaced apart more than two times the biacromial width. This spacing will decrease the stress on the posterior capsule and surrounding tissues, and promote shoulder abduction greater than 80 degrees and shoulder extension greater than 15 degrees. Handoffs are mandatory during bench presses, and only the flat bench is
recommended (Fees et al. 1998).

Shoulder presses should be modified by using a power rack or Smith machine to avoid stress with increased horizontal translation.

Proper positioning of the scapula will maximize joint congruency and ensure that glenohumeral translation is decreased and stability is increased by the activity of the rotator cuff and biceps. With posterior instability as with anterior instability, the strength of the rotator cuff and scapular muscles is likely the most important consideration (Hertling & Kessler 1996).

Impingement

Impingement at the shoulder can occur secondary to glenohumeral instability, muscular imbalance, supraspinatus weakness or a deformity that causes compression on the subacromial space. Impingement syndrome occurs when a rotator cuff tendon—usually the supraspinatus—is encroached on under the subacromial arch. Tissues that reside in the narrow space of the coracoacromial arch become irritated from being torn, pinched or squeezed. The onset of injury can be gradual and insidious, or can be the result of a trauma suffered in a direct blow or fall.

The most pain-provoking position with this injury is internal rotation. According to Burkholder, “Whether [athletes] have tendinitis, a tear or an instability, it seems that they get impingement as a secondary problem. I try to keep our athletes from going above 90 degrees in abduction.”

Exercises that increase stress on the irritated area should be avoided. See “Considerations With Impingement Syndrome” for specifics.

Modifications. A common mistake is to perform lateral raises that rise above shoulder level, increasing the risk of impinging a tendon under the subacromial arch.

The glenohumeral joint should always be externally rotated into a thumbs-up position during lateral raises to create a larger opening under the subacromial arch (Einhorn 1985).

With bench presses, hand spacing should be modified to a narrower grip (slightly beyond shoulder width) to open up the area of impingement. If the athlete has a known pathology at the acromioclavicular (AC) joint—for example, a hooked acromion—an underhand grip will likely diminish discomfort and allow the movement to be performed.

Pull-ups can be irritating with a shoulder impingement, but using a grip in which the palms face the athlete can ease the stress on the affected area.

Most exercises should be performed in a functional plane—either anterior to the scapular plane or in the scapular plane. Exercise in the coronal plane will often exacerbate symptoms and is likely nonfunctional.

The external rotators (infraspinatus and teres minor) are often much weaker in an individual with an impingement, so attention should be given to their development. Keep in mind that even in a healthy athlete, the strength of the internal rotators will likely override that of the external rotators (Leroux et al. 1995). In one study, isokinetic testing of asymptomatic individuals demonstrated 30 percent greater strength in the internal rotators when compared to the external rotators (Warner et al. 1990).

Check clients for an appropriate ratio of strength between the internal and external rotators. Are the internal rotators (lats, pectorals) tight and disproportionately strong? Are the external rotators too weak?

Glenoid Labrum Damage

The glenoid labrum (the fibrocartilage ring attached to the rim of the glenoid to deepen the fossa) is the primary site for the glenohumeral ligaments to attach. A SLAP (superior labrum anteroposterior) lesion may result when an athlete falls onto an outstretched hand or shoulder, or it can be associated with rotator cuff tendinitis or tears. This injury commonly occurs when baseball players slide or fall down during a fielding play. The injured athlete will usually feel pain when performing exercises that require the shoulder to be placed in abduction, external rotation or extension (high-five position). See “Considerations With Glenoid Labrum Damage” for specific exercises to avoid.

Modifications. When performing bench presses, an athlete with a SLAP lesion should use a narrower grip and alternate between overhand and underhand to decrease microtrauma to surrounding tendons (Fees et al. 1998).

When performing flyes, the exerciser should imagine a plane stretching straight out from the flat bench, and extend no farther than that imaginary plane. Neck presses and pull-downs should be
executed in front of the body. Shoulder presses can be done within the limits of a Smith machine or power rack, either of which will promote control during the upward and downward motions, preventing unsteadiness and subsequent stress in the horizontal plane. With a SLAM lesion as with an anterior instability,
bar squats are better performed with a
center-of-mass bar, or with a bar secured in front of the body.

Shoulder stability must also be addressed in athletes with a labral lesion, since this condition is often, though not always, associated with a capsular injury (Hara, Ito & Iwasaki 1996).

Getting in the Game

In the forward-moving world of high-school and collegiate athletics, treating the injured athlete demands a team approach that includes the care of a physician, athletic trainer or physical therapist, and personal trainer or strength and conditioning coach. Each person involved in recovery plays an important role in helping the athlete return to his or her sport physically and mentally prepared. Communication among all parties is a must. Employing well-designed weight training modifications will not only enable the athlete to return to the court or playing field with more confidence but will also help establish you as a safe and intelligent trainer in the eyes of the medical and athletic communities.