A powerlifter with shoulder pain

I had a power lifter today with a sore shoulder. Super common. He was getting pain at the front of the shoulder when he bench-pressed. Interestingly, not when he overhead pressed. It has begun to interfere with his bench gains, and that’s not OK.

I’ve also been treating him for left low back pain. This will become important later. 

Originally I thought this patient was experiencing impingement pain. He had issues with his posterior oblique sling (lat activity and opposite glute activity), which I thought was leading to a compressed shoulder. I sent him home with his correctives to do. A few weeks later, and still no relief.

So he came back in and I reassessed. Turns out, his shoulder pain wasn’t so much along the joint line as it was localized to the coracoid process. Silly me. I got bit on my ass for not assessing better. 

I was half-right though. These muscles WILL compress the shoulder joint if they shorten too much. And he STILL had to do those correctives in order to optimize power through that sling, and that STILL would have been my first port of call for getting his shoulder better, even given what I now know. Sometimes rehab, like training, can be a process of trial and error. Even though the diagnosis may have changed, the management would have been the same. However now that that management hasn’t worked, we need to think a little bit more out the box.       

I keep coming back to his intrinsic core. He’s had some issues there before.  Historically, his transverse abdominus or psoas shuts down, the sequelae of which is that his left lumbar erector gets cranky. Today, it turns out, his left transverse abdominus continues not to fire. This was improved with some scar localization, but even MORE so when he rolled his shoulder forward. 

If the intrinsic core is compromised, everything else will be.  If you lose the ability to create intra-abdominal pressure, or stabilize yourself safely around your centre of mass, your body will stabilize itself somewhere else to create the impression of safety. SOMETHING needs to be stable in order to create power.  You can’t fire a cannon in a canoe. You can’t bench press off an unstable base. If the intrinsic core is not doing an adequate job of creating stability, very often the shoulder will roll forward, or will hike up towards the neck, and compress AT the shoulder joint or AT the neck.

So let’s have a closer look at the intrinsic core muscles. To create intra-abdominal pressure, we have the diaphragm descending inferiorly (concentric contraction) onto an eccentrically contracting transverse abdominus, internal abdominal oblique and pelvic floor. The multifidi then contract to stabilize our lumbar spine against this increasing pressure and create neutral lordosis. And voila, we have stabilized our centre of mass.  From here, now we have a stable base to move off of, we can then begin to recruit other muscles to create more complex stability or movement. 

The powerlifter’s bench press is a contentious topic for this reason.  In an “open scissor” posture, where the diaphragm cannot descend ideally onto the pelvic floor, can enough intra-abdominal pressure be created to provide a stable base off which to then move the shoulder safely? This topic is hotly debated amongst practitioners and movement therapists.  Some would say yes, some would say never.  The ‘extension-compression’ stabilization strategy used in the sport, where they encourage hyperextension of the lumbar and thoracolumbar spine, would be considered by many to be dysfunctional. Yet for the particular task at hand, it would appear that it is the MOST functional way to horizontally push hundreds of kilograms against gravity. 

So let’s assume that this position is the one that is going to be used to create stability.  What changes? Firstly, the posterior diaphragm will tend not to descend as far as the anterior diaphragm.  They will lose their lateral stability and most of their pressure will escape anteriorly via the rib flare into the anterior abdomen.  This rib flare, when becomes habitual, will deactivate transverse abdominus and internal oblique. Anterior diaphragm will overwork, which, remember, shares fascial attachments with internal oblique and transverse abdominus. Also, given their antagonistic relationship (ie. diaphragm is an inhalatory muscle, the other two are exhalatory), if diaphragm tightens up it will shut the other two off.   

Transverse abdominus and internal oblique are the body’s natural weightlifting belt! Creation of good intra-abdominal pressure means descending the diaphragm down whilst the transverse abdominus and internal oblique loads AGAINST that contraction (ie. into an eccentric phase). In other words, your intra-abdominal pressure is dysfunctional if the pressure is just escaping anteriorly, and the transverse abdominus and internal oblique aren’t doing their job to push back AGAINST that build of tension. 

You can try this on yourself: breathe deeply into your belly. Notice if it is just escaping out the front, with no real pressure increase on the sides of your body.  Now imagine you are pushing your diaphragm DOWN towards your pelvic floor.  You might feel your lower ribs descend on each side. Your breathing should now have changed. You should feel you breathe more into the sides, not just the front.  NOW you are putting that transverse abdominus and internal oblique to work, as you have created the optimum environment in which they can fire off.  Remember, with all of this, the more relaxed you can be, the better you will perform. Play with the subtleties of these movements at rest. You will only need large amounts of intra-abdominal pressure once you load up (and even then, the more relaxed you can be, the more energy you will have to perform the lift. Note I am NOT saying to go flaccid!).      

So that is the first question: should lifters be spending extra time working on transverse abdominus and internal oblique activation when they are not under the bar so that they can nullify transfer of that ‘open scissor’ posture into daily life? Or would this actually make them worse at their sport by taking away specific adaptations? The same could be said for other sports-specific adapations. For example, baseball pitchers tend to have excessive amounts of shoulder external rotation and minimal internal rotation. Should they be spending time working on their internal rotation in the off-season? For performance, maybe their time would be spent better elsewhere. However, for longevity in the sport, maybe they should. 

The argument of specificity comes with its own bag of worms. Obviously, training specificity is hugely important for performance. But just how important? This is another debated topic. I believe that accessory work should be just that: accessory to what they are already doing. This includes working into different ranges of motion, working in different activities, strengthening different body regions.

I base this on a few thoughts (let’s not make this an argument about research, these are my opinions based on what I’ve read and experienced, and no I can’t cite most of it.  If you have cool stuff, show it to me though, always down to upgrade my thinking!):

1.     A muscle that can’t relax and lengthen (ie. load eccentrically), can’t create as much power in the concentric phase

2.     Most injuries seem to occur during the eccentric phase (hamstring strains for instance occurring during the swing phase).  Therefore, eccentric training is of utmost importance to injury prevention

3.     There is research to show that training the opposite movement still improves muscular strength and endurance.  Eg. Training pull-ups has been shown to still improve an overhead press

4.     Strong organisms don’t survive, adaptable organisms do

5.     Somewhat Feldenkrais-y, but training alternative movement patterns is creating new neural pathways for movement that improve the quality of ALL movement

6.     In my opinion, a lot of injuries occur because the brain is running on the same repeated loading patterns and has lost the ability to be CREATIVE with movement and choose from alternative loading patterns.  Training that challenges neuromuscular activity in this way is therefore highly beneficial.  

7.     You can only upgrade your movement if you practice being creative with your movement

So, anyway, back to my lifter: 

1. He will release around his coracoid process, taking care not to be too rough so that it causes tingling all the way down his arm! This could look like a ball release or stretching into horizontal abduction and extension or a combination of the two.  Follow along the pec minor, coracobrachialis and short head biceps muscles.

2. When not under the bar, I would recommend lifters spend EXTRA time working on transverse abdominus and internal oblique activation and nullifying transfer of that ‘open scissor’ posture into daily, habitual life, if purely for the experience of having another movement option available to them! He will do this by coming into a low quadruped position where his low back is in neutral or even a flexed position, and he practices lateral breathing, not just anterior breathing. 

3. I want him to practice activating his intrinsic core in a sport-specific position (eg. bench press position) by lifting one leg at a time slowly into the air, keeping core on and not feeling hip flexor or shoulder overwork.  I suppose this would look like a sports-specific modified dead bug.  With all this stuff more is not better, better is better.  He should MAKE SURE he feels it in his abdominals and he has an awareness of these muscles.  Otherwise, he needs to stop and reset.   

4. I want him to do a modified bird-dog on forearms so that he can really work his shoulder stability in this position whilst still working on core control.  I don’t want his pelvis to rock and I want him to also feel support through his serratus anterior, preventing scapular winging and wrapping around through the back of his ribs, instead of pushing away with his anterior shoulder (this should remain soft).      

5. He will stop bench pressing for one week, and start pulling, bringing awareness to antagonistic muscles like posterior deltoid, latissimus dorsi and shoulder retractors.   

We will catch up in a week and begin to reload.