ONE OF THE PRIMARY RESPON-sibilities of the personal trainer orstrength and conditioning special-ist is educating clients in properexercise techniques. More impor-tantly, however, the strength andconditioning professional must beable to design exercise programsthat are appropriate and safe foreach client. Because there is awide range of exercises to choosefrom when targeting specific mus-cles or muscle groups, it is sensi-ble to avoid exercises that aremore likely to lead to injury.
Injuries to the shoulder arerelatively common among weighttrainers and can be career-threat-ening to those at the competitivelevel (14, 26). Fortunately, mostshoulder injuries from resistancetraining are minor musculo-ten-donous strains or ligamentous-capsular sprains. However, whenimproper exercises or exercisetechniques are utilized, resistancetraining may exacerbate or con-tribute to the development ofglenohumeral joint hyperlaxity,
instability (19, 21), or impinge-ment (8, 9, 12, 16).
In this article we will identifyshoulder exercises commonly per-formed in fitness centers that maycontribute to or exacerbate gleno-humeral joint injury. Alternativeexercises that may be substitutedwill be described along with the ra-tionale for the variations. It is be-yond the scope of this article to pre-sent an exhaustive review ofcontraindicated exercises for allknown shoulder pathologies;rather, glenohumeral joint patholo-gies commonly associated with re-sistance exercises will be dis-cussed. Avoiding risky exerciseshelps prevent injury in healthyclients and further tissue damagein clients recovering from injury.
■ Glenohumeral Instability
The glenohumeral joint is very mo-bile but lacks bony congruency,rendering it vulnerable to exces-sive laxity (hyperlaxity) or instabil-ity. Glenohumeral joint hyperlaxi-ty or instability may occur as the
result of a congenital hypermobil-ity, a traumatic injury, or a grad-ual loosening of the ligamentous-capsular restraints (19, 21).Repeated stretching of ligamen-tous-capsular restraints increasesthe likelihood of permanent elon-gation (acquired ligamentous laxi-ty) and injury (10, 21). If a liga-ment or capsule is loosenedsignificantly, surgery may be nec-essary to restore stability. Jointhyperlaxity involves excessive mo-bility without the presence of pain,whereas painful and uncontrol-lable excessive joint movementcharacterizes joint instability (21).When the static glenohumeral lig-amentous-capsular restraints areexcessively lax or unstable, the dy-namic rotator cuff muscles arethought to exert greater force tostabilize the humeral head (10).This dynamic compensation oftenresults in fatigue followed by rota-tor cuff tendonitis and pain. Sen-sibly, exercises that impart signif-icant stresses to the glenohumeralligamentous-capsular restraints
October 2001 Strength and Conditioning Journal 11
should be avoided, particularly ifpreexisting instability or hyperlax-ity is present.
Anterior Glenohumeral Instability
The anterior glenohumeral jointcapsule is the most common siteof hyperlaxity and instability inthe shoulder (4). Since shoulder(humeral) external rotation com-bined with abduction and hori-
zontal abduction (Figure 1) maxi-mally stresses the anterior cap-sule (6, 17–19), this movementcombination should be avoidedduring resistance exercises in in-dividuals with anterior hyperlaxi-ty or instability. Examples of com-mon exercises that put theglenohumeral joint in the “at-risk”(6) position (external rotation com-bined with abduction and hori-zontal abduction) include thelatissimus pull-down performedbehind the neck, the shoulderpress performed behind the neck,the wide-grip bench press, and thepectoralis fly.
Exercises commonly per-formed behind the neck (e.g.,shoulder press and latissimuspull-down) should be performedwith the elbows approximately 30ºanterior to the shoulder in theplane of the scapula (scaption) todecrease stress to the anteriorglenohumeral joint capsule (21).The combination of shoulder ex-ternal rotation, abduction, hori-zontal abduction, and excessivecervical spine flexion during thebehind the neck latissimus pull-down was blamed for 1 reportedcase of temporary arm paralysisfrom brachial plexus injury (23).The latissimus anterior pull-downto the chest can be substituted totrain the latissimus dorsi, rhom-boids, and elbow flexors withoutcompromising the anterior gleno-humeral joint.
Overhead (military) shoulderpresses are typically performedbehind the neck, placing theshoulders in the at-risk position.Performing the shoulder presswith the hands and elbows anteri-or to the shoulder is preferablewhether using a bar (preferablywith a spotting rack), dumbbells,or a machine. In our clinic, pa-tients are instructed to face back-ward on the seat when using theshoulder press machine (Figure
2). This modification assures thatthe shoulders will avoid the at-riskposition throughout the lift.
Another exercise usually per-formed with the weight positionedbehind the neck is the back squat.During the back squat the shoul-der is maintained in an externallyrotated, abducted, and horizontal-ly abducted position. Clients withglenohumeral anterior hyperlaxityor instability should be instructedto either use a modified center ofmass bar (13) or perform a frontsquat instead. The elbows are po-sitioned anterior to the shoulderwhen using a modified center ofmass bar (13) or performing afront squat, substantially decreas-ing anterior glenohumeral liga-ment stress. If front squats areperformed, we recommend usinga self-spotting rack (e.g., Smithrack) to prevent injury if there is aloss of control of the weight.
The wide-grip flat bench press(barbells or dumbbells) or theseated machine chest pressshould be modified to avoid exces-sive horizontal abduction. Casesof bilateral anterior shoulder dis-location during bench pressinghave been reported as a result ofthe horizontal abduction stress onthe anterior glenohumeral liga-ments combined with heavy resis-tance (1, 11). Excessive horizontalabduction during the bench presscan be avoided by limiting handspacing to 1.5 times the shoulderwidth (7), placing a cushion or rollon the chest, or using a range ofmotion (ROM) limiting stop on amachine or self-spotting rack.Likewise, limiting hand spacingand horizontal abduction on achest press machine protects theanterior glenohumeral capsulo-ligamentous restraints. Clientswith hyperlaxity or instabilityshould approach the weighted barincline press exercise with cautionas the arms are maintained in the
Figure 1. Arm (humeral) external rota-tion combined with horizon-tal abduction.
12 Strength and Conditioning Journal October 2001
at-risk position throughout theentire movement (5). Alternatively,dumbbells may be employed dur-ing the incline press with carefulavoidance of the at-risk position.Conversely, throughout the entiremovement of a decline press, thearms are maintained in a safe po-sition below 90º flexion and 45ºabduction with minimal externalrotation making this a reasonablysafe pectoral strengthening exer-cise with a weighted bar or dumb-bells.
Like the bench press, handspacing during push-ups shouldalso be limited to reduce horizon-tal abduction. An alternative tech-nique for performing a push-upusing a standard weight bench isdemonstrated in Figure 3. This ex-ercise can be performed from akneeling or standard push-up po-sition. In addition to reducedstress on the anterior gleno-humeral ligaments due to the nar-rowed grip and decline movement,our clients have reported lesswrist discomfort with this push-up technique compared with thestandard push-up technique per-formed on the floor.
Another common strengthen-ing exercise for the anterior shoul-der and chest musculature is thepectoralis fly. Excessive horizontalabduction should be avoidedwhen performing this exercise inorder to minimize anterior capsu-lar distention. This can be accom-plished by instructing clients toinitiate the movement with theirelbows slightly in front of theirshoulders (scapular plane) and tomaintain their elbows belowshoulder level throughout themovement. The elbows should bekept below shoulder level to re-duce shear across the subacromi-al space, which may irritate therotator cuff tendons and bursa.Clients may need to practice thistechnique on a pectoralis fly ma-
chine before attempting the move-ment with free weights.
Stretching the pectorals withthe arm horizontally extended andexternally rotated should be avoid-ed in individuals with anterior
glenohumeral joint capsular hyper-laxity or instability. Although thepurpose is to stretch the pectoralismuscle, the noncontractile anteri-or capsule is also stretched withthe arm in horizontal abduction
Figure 2. Military press performed anterior to the shoulder.
October 2001 Strength and Conditioning Journal 13
and external rotation. An alterna-tive technique for pectoral stretch-ing is illustrated in Figure 4. Thisstretch primarily affects the pec-toralis minor; however, the pec-toralis major will also receive a mildstretch when performed properly.
Posterior Glenohumeral Instability
Just as stretching the anteriorglenohumeral joint capsule mayexacerbate an anterior instability,stretching the posterior capsulemay exacerbate a posterior gleno-humeral instability. The posteriorglenohumeral joint capsule isstressed when weight is bornethrough the arm with the shoul-der flexed (e.g., narrow-grip benchpress or push-up), or when theflexed shoulder is pulled forward(e.g., eccentric phase of rowing ex-ercise) or across the chest (18, 21,24). Obviously, strengthening andstretching exercises that stress a
posteriorly unstable shoulder mayneed to be avoided entirely. Thecross-chest stretch should beavoided if a posterior instability ispresent. In addition, rowing exer-cises should be modified to reducethe amount of arm distractionduring the eccentric phase of therow. Clients can be instructed tobegin and finish the rowing move-ment with their elbows slightlybent to reduce posterior capsularstretching. Deadlifts and powercleans might also need to beavoided or modified if a posteriorinstability is present. Both ofthese exercises stress the posteri-or capsular restraints as the armis pulled forward when attemptingto lift or lower the weight from thefloor. The deadlift might need to beavoided entirely; however, thehang clean can be substituted forthe power clean, eliminating thepull from the floor.
Figure 3. Alternative push-up technique using standard weight bench.
Figure 4. Pectoralis stretching tech-nique for clients with ante-rior glenohumeral hyperlax-ity or instability. (a) Restshoulder to be stretchedagainst corner of wall usingtowel cushion. (b) Initiatestretch by squeezing (re-tract) shoulder blades(scapulae). (c) Greaterstretch may be obtained byusing the opposite hand topull the pectoral musclestoward the midline of thebody.
14 Strength and Conditioning Journal October 2001
Hand placement should be ad-justed when attempting to per-form the bench press or push-upin the presence of a posterior in-stability. In contrast to the narrowgrip recommended during thebench press or push-up for shoul-ders with anterior instabilities, in-dividuals with a posterior instabil-ity should use a wider grip todisperse direct force through thearm and into the glenoid fossa.
■ Subacromial Impingement
Primary Impingement Syndrome
Repeated compression of the rota-tor cuff tendons and bursa againstthe overlying acromion and/orcoracoacromial ligament may leadto irritation and inflammation.When the cuff tendons and/orbursa are inflamed, the subacro-mial space is further diminishedand the tendons and bursa areoften impinged (pinched) in thesubacromial space—a conditionknown as primary subacromialimpingement (16). Individualswith a primary impingement oftenexperience pain when lifting theiraffected arm (particularly aboveshoulder level) because of com-pression of the inflamed and sen-sitized cuff tendons and bursa.Several resistance exercisesshould be modified to prevent in-ducing or exacerbating a primaryimpingement.
The lateral raise, an excellentexercise to strengthen the middledeltoid and supraspinatus, iscommonly performed with thepalm facing down (internal rota-tion of the glenohumeral joint),which can lead to rotator cuff im-pingement (Figure 5). During ele-vation of the arm, the rotator cufftendons normally move with min-imal compression beneath theoverhanging acromion. If the armis internally rotated during eleva-tion, however, the greater tuberos-
ity of the humerus pinches the ro-tator cuff tendons and bursaagainst the acromion (8). Repeti-tive pinching can lead to inflam-mation and damage of the rotatorcuff tendons or bursa (16). Tominimize compression, elevationexercises should be performed
with the arms externally rotated.Clients should be instructed touse a neutral grip done by point-ing their thumbs toward the ceil-ing to promote arm external rota-tion (Figure 6). Seated lateral raisemachines that require elevationwith concomitant internal rotation
Figure 5. Lateral raise on machine with concomitant humeral internal rotation.
October 2001 Strength and Conditioning Journal 15
should be avoided (Figure 5). Lat-eral raises with the arm external-ly rotated using dumbbells may besubstituted.
Another exercise that maylead to subacromial impingementis the upright row. During thisexercise the arm is maintained inan internally rotated positionthroughout the full range of eleva-tion. We recommend either avoid-ing this exercise entirely or limit-ing elevation to 80º and keepingthe elbows lower than the shoul-ders to avoid rotator cuff impinge-ment.
Subacromial impingement canalso be exacerbated by exercisesthat involve excessive flexion (16).The pullover exercise performedsupine with free weights (Figure 7)or on a machine forces the rotatorcuff tendons and bursa againstthe undersurface of the acromionwhen the arms are hyperflexed.This exercise can be made safer bysimply limiting flexion to the nor-mal physiological limits or a com-fortable ROM. Alternatively, latis-simus pull-downs performed infront of the body, which challengeidentical muscle groups, may besubstituted.
SecondaryImpingement Syndrome
Exercises that contribute to hy-perlaxity of the anterior gleno-humeral joint (discussed previ-ously) can also contribute to thedevelopment of a secondary rota-tor cuff impingement (10, 12). Ifthe arm does not remain centeredin its shallow fossa during move-ment, the rotator cuff tendonsand bursa can be repetitivelycompressed and become in-flamed. In addition, the rotatorcuff muscles must work harder inan attempt to restore stability andbecome prone to fatigue, ten-donitis (microtrauma), inflamma-tion, and subsequent impinge-
ment. This condition is referred toas a secondary impingement (10,12) because the impingement de-velops secondary to hyperlaxity orinstability. With secondary im-pingement it is sensible to avoidrepeated stress to the anteriorcapsular restraints by limiting ex-
ercises that combine arm externalrotation with horizontal abduc-tion. Therefore, the modificationsfor anterior shoulder instability orhyperlaxity should be followedwhen prescribing exercises for anindividual with a secondary im-pingement.
Figure 6. Scaption–lateral raise in the scapular plane (30º anterior to the frontalplane).
16 Strength and Conditioning Journal October 2001
Internal Impingement Syndrome
Internal impingement of the artic-ular side of the supraspinatus andinfraspinatus tendons against theposterior glenoid labrum mayoccur when the shoulder is in theat-risk position (Figure 1; 3, 9).This form of impingement is mostprevalent in throwing athletes be-cause of repetitious shoulder ex-ternal rotation combined with ab-duction and horizontal abduction,which can impinge the tendonsagainst the labrum. Anteriorglenohumeral instability may be acontributing factor to the develop-ment of internal impingement (2,10). Sensibly, exercises that in-duce posterior glenohumeral jointimpingement pain (not musclesoreness) and/or exacerbate ananterior instability should beavoided. Performing shoulder ex-ercises out of the at-risk positionis recommended.
■ RecommendedShoulder Exercises
Weight trainers frequently developthe larger shoulder muscle groups(i.e., pectorals and deltoids), yetoften fail to develop the smaller ro-tator cuff and scapular stabilizers.This pattern of weakness andasynchronism in the smallershoulder muscle groups wasfound to occur in a group ofweight trainers who were unableto continue lifting because ofshoulder pain (6). We recommendthat exercises that develop all ofthe muscle groups about theshoulder, not just the larger mus-cles, be provided to clients. In ourclinic, most patients with shoulderdysfunction 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 [Figure8], and horizontal abduction with
Figure 7. Pullover exercise performed supine.
Figure 8. Press-up performed on a standard weight bench.
October 2001 Strength and Conditioning Journal 17
external rotation) was shown toelicit high levels of electromyo-gram (EMG) activity in all of theshoulder muscles. Internal andexternal rotation exercises in neu-tral or at 90º abduction (Figure 9)are also commonly prescribed forpatients with shoulder dysfunc-tion (3). Overhead athletes need todevelop strength in the intrinsicrotator cuff muscles to steer thehumeral head in an inferior direc-tion while the arm is elevated. In-adequate strength can lead to ex-cessive humeral head elevationand subsequent impingement ofthe soft tissues beneath theacromion (22).
As with any unfamiliar exer-cise techniques, we encourage youto practice the exercises describedabove before instructing clients.Proper exercise technique is vitalto the safety of any resistance-training program. It is also imper-ative that the training program becomprised of exercises that areappropriate for the individualclient’s goals and anatomy.
The certified strength and con-ditioning specialist and personaltrainer are increasingly being re-cruited to assist in the rehabilita-tive process. This shift in respon-sibility requires the strength andconditioning specialist to developan awareness of appropriate andinappropriate exercises for a vari-ety of pathologies. When in doubtabout the safety of a particular ex-ercise for a client recovering frominjury, consult with the appropri-ate healthcare provider. Clientswho sustain exercise-induced in-juries that limit functional abilityshould be referred to their prima-ry care provider. ▲
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Chris J. Durall, MS, PT, ATC,CSCS, is an assistant professor inthe Physical Therapy Program atCreighton University in Omaha,NE and is a physical therapist atSt. Joseph Hospital at CreightonMedical Center in Omaha, NE.
Robert C. Manske, MPT, CSCS,is an assistant professor in thePhysical Therapy Program at Wi-chita State University and is aphysical therapist at Via ChristiOrthopedic and Sports Medicinein Wichita, KS.
George J. Davies, MEd, PT, SCS,ATC, CSCS, is a professor in thePhysical Therapy Program at theUniversity of Wisconsin-LaCrossein LaCrosse, WI, and director ofClinical Research Services at Gun-dersen Lutheran Sports Medicinein Onalaska, WI.
