READING time – 5-10 minutes
There are two distinct pathological categories of shoulder injury. In the older population, shoulder injury is generally a result of the degenerative aging process. In the younger population, it is commonly a result of the repetitiousness of an overhead sport (Jobe & Pink, 1993).
As an amateur athlete, how many of you have had pain or a twinge in the shoulder? Certainly as a therapist stepping into the world of crossfit, client percentages with shoulder pain have shot up. Now, why is that? Do we accept the general consensus from outside of crossfit that the sport is dangerous? I don’t agree. In my opinion it is no more dangerous than the typical weightlifter snatching or the gym junkie benching 4 times per week.
I haven’t come across any research that shows evidence for a higher prevalence of injury in the crossfit sport compared to any other sports. In fact, one could argue that it might be safer. Your training is programmed for you and you are being coached in how to perform the exercises safely. It has less external elements of danger than football does as an example. You’re not at risk of receiving a high two footed challenge in your local box that may put your career at risk. Furthermore lets compare it to the regular gym junkie; I have trained and treated within a large corporate gym and seen for myself the awful technique and lack of coaching a lot of these guys/ladies use/receive. We know that bad form is probably the most likely way of sustaining an injury.
However, with the amount of overhead lifting/activity we perform during crossfit, it is more likely we will sustain an injury, especially in an dysfunctional, immobile joint. So why is your shoulder hurting? Is it that simple? Have a look below at the common shoulder injuries in overhead athletes.
CLASSIFICATION OF 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
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 “sub acromial 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 in my 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 with pressing, snatching, jerking, handstands/push ups and kipping.
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. This is why 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.
To train or not to train?
Training through pain will likely cause symptoms to worsen. 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 (http://ard.bmj.com/content/53/6/359.short).
My advice initially is to minimise pain through ice and avoid aggravating movements. 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. We need to avoid activities that involve humeral (arm) elevation and focus on pain free exercise. Why not take the opportunity to work on your squat and work on your biomechanical abnormalities? (Perfect cue to read my next blog)!
Through the coaching in crossfit your technique issues shouldn’t be the problem. From my experience with the coaches I work with, they are great at identifying incorrect form and know when to introduce scaled movements. 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 around one injury to the shoulder. Symptoms can be very similar in appearance and it is important you do not go away from this and assume you have SAI. My advice is to seek medical advice through your local sports therapist / physio / GP / Consultant.
I hope you find this of interest and thanks for taking the time to read it. Please feel free to get in touch with any questions and if you are in pain, seek help!
Train hard, train safe, train clever!
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