Group classes, overhead activity & the problematic shoulder

There are two distinct pathological categories of shoulder injury. In the older population, shoulder injury is generally a result of the degenerative ageing process. In the younger population, it is commonly a result of the repetitiousness of an overhead sport (Jobe & Pink, 1993).

The problematic shoulder in group classes

As an active individual, how many of you have had pain or a twinge in the shoulder? Within a group class setting, you will undoubtedly come across a few individuals who are currently suffering or have suffered from some form of shoulder pain since partaking in this form of exercise. This is not to say that group exercise classes are going to cause shoulder pain as there are many explanations for why this type of pain occurs, and along with this there are many ways to avoid it happening altogether.

Research suggests that soft tissue injuries, such as those found in the shoulder, are commonly caused by overuse and overload of the muscle/tendons in that area due to improper technique/form or excessive overtraining (Gabbett, 2016). You may compare the group exercise classes and your average gym junkie and conclude that group classes are safer as you are being led by an instructor with knowledge and experience to keep you safe, however, these classes may not be tailored to individual abilities. This generalised programming for a whole class can be where the downfalls occur – although we have an experienced instructor leading a class, their time is split so ensuring the technique is good for all participants in a class of 8+ can be quite a challenge.

Rather than stepping away from these group classes completely, it’s important to educate and understand for yourself how to train safely and effectively – this will not only help you avoid getting injured but will also enhance your training drastically.

Have a look below at the common shoulder injuries in overhead athletes.

The problematic shoulder: Classification of the most common shoulder lesions in overhead athletes (Jobe & Pink, 1993)

• Rotator Cuff Lesions – Tendonitis, Tendonosis, Strains, Bursitis
• Rotator Cuff Tears – Partial thickness, Full thickness, Internal impingement
• Glenohumeral Joint Capsular Lesions – Laxity, Instability, Capsulitis
• Superior Labral Tear (SLAP) – Frayed (type I) Tear (type III, IV) Detached (type II) Peel-back
• Osseous Lesions – Glenoid osteochondritis dissecans, Bennett’s lesion
• Biceps Tendon Lesions – Tendinitis, Tendonosis, Subluxation
• Neurovascular Lesions – Axillary neuropathy, Thoracic outlet syndrome, Brachial neuritis

The problematic shoulder and the most common shoulder injury

Following a thorough assessment, it is sometimes very hard to identify the exact injury without imaging/investigations. A lot of the time we, therefore, categorise the injury under the term “subacromial impingement” (SAI). SAI can be caused by a number of structures being compromised in the subacromial space (this is the space shown by the red circle in the picture above, between the humerus (arm) and the acromion (top of the shoulder which forms the end of the shoulder blade). SAI is the most common shoulder injury I see at the clinic.

What exactly is SAI?

It involves a mechanical compression of the supraspinatus tendon, the subacromial bursa, and the long head of the biceps tendon, all of which are located under the coracoacromial arch (Voight & Prentice). This often occurs with repetitive overhead movements such as overhead presses, bench presses, and push-ups.

Why do we get SAI?

The problem causing this injury could have been building some time ago with inactive lifestyles, poor postures or even previous injury. You may just be an unlucky individual and have an abnormally shaped acromion.

A number of possible causes are listed below:
– Shoulder stiffness
– Strength ratio imbalance/rotator cuff weakness
– Shoulder instability
– Poor scapular control
– Poor technique
– Training overload

How do we treat/rehabilitate SAI?

Firstly, it is important to understand there is no set protocol for treating and rehabilitating SAI as everyone is different. If you begin to strengthen structures that are overly dominant, then you are going to make the problem worse. I could list a number of exercises to perform but I may be leading you down the wrong path. Therefore, it is important to get a full examination and assessment done to find out why you have pain in the shoulder and where the imbalances/abnormalities are. The findings will construct a safe treatment and rehabilitation programme enabling you to carry out the correct exercises.

The problematic shoulder: To train or not to train?

Training this area through pain will likely cause symptoms to worsen, however, this does not mean that training needs to come to a complete halt. SAI has been described as a continuum during which repetitive compression eventually leads to irritation and inflammation that progresses to fibrosis and eventually to rupture of the rotator cuff (Riley et al., 1994).

My advice initially is to minimise pain through ice and avoid aggravating movements (this is usually any form of push movement). Of course, each individual case is different, but usually, modification to exercise is enough to offload the structures that are causing the pain. Overhead activities are most likely a no-no, so instead, we opt for pull movements that allow these anterior structures to take a breather. We need to avoid activities that involve humeral (arm) elevation and focus on pain-free exercise. To do this with a group class, it is important to tell your instructor that you are currently suffering from a shoulder injury, make them aware of those aggravating movements and discuss adaptations to exercises so that you can still get the most out of your training without causing symptom flare-ups and further irritation.

Summary: How to deal with a problematic shoulder

Through proper coaching and load management during classes, your technique issues shouldn’t be the problem. From experience, instructors and coaches are great at spotting incorrect form and overload and know exactly how to alter movements, when necessary, but it is just as important as the participant themselves to be aware of their own bodies and what they can do to stay safe and train effectively. However, injuries happen and sometimes not much can be done to prevent them.

On the other hand, there are certainly ways to reduce the likelihood of an injury. Prehab can be the key to avoiding shoulder pain. But how do you know what to strengthen and what to stretch?
A biomechanical assessment will help identify any weaknesses/dysfunction you may have which will increase your chances of shoulder pain. Find out what’s not working right and then build a prehab programme following this.
REMEMBER – this info is based on one injury to the shoulder. Symptoms can be very similar in appearance, and it is important you do not read this and instantly assume you have SAI. My advice is to seek medical advice through your local sports therapist/physio/ GP/Consultant.

Train hard, train safe, train clever.

References

Jobe & Pink (1993). Classification and treatment of shoulder dysfunction in the overhead athlete. J Orthop Sports Phys Ther, 18(2):427-32.

Gabbett, T. J. (2016). The training—injury prevention paradox: should athletes be training smarter and harder? British journal of sports medicine, 50(5), 273-280.

Riley GP et al., (1994). Tendon degeneration and chronic shoulder pain: changes in the collagen composition of the human rotator cuff tendons in rotator cuff tendinitis. Ann Rheum Dis., 53(6):359-66.