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Exercise Modification Strategies to Prevent and Train Around Shoulder Pain

Article  in  Strength and conditioning journal · December 2016

DOI: 10.1519/SSC.0000000000000259

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 Exercise Modification
Strategies to Prevent and
Train Around Shoulder
Pain
Guillermo Escalante, DSc, ATC, CSCS, CISSN
Department of Kinesiology, California State University San Bernardino, San Bernardino, California
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/nsca-scj).
ABSTRACT
THIS ARTICLE PROVIDES A SUM-
MARY OF THE LITERATURE
RELATED TO SHOULDER PAIN IN
STRENGTH ATHLETES. THE PREV-
ALENCE OF SHOULDER INJURIES
AND TYPES OF SHOULDER INJU-
RIES SUSTAINED WILL BE RE-
VIEWED. EXERCISES THAT MAY
PREDISPOSE STRENGTH ATH-
LETES TO SHOULDER INJURIES
AND SUGGESTIONS OF SPECIFIC
EXERCISE MODIFICATIONS TO
REDUCE THE RISK OF INJURY WILL
BE DISCUSSED. FINALLY, PRE-
VENTIVE STRATEGIES TO REDUCE
THE LIKELIHOOD OF SHOULDER
INJURIES WILL BE ADDRESSED.
FOR A VIDEO ABSTRACT
DESCRIBING THIS ISSUE, SEE
VIDEO, SUPPLEMENTAL DIGITAL
CONTENT 1, HTTP://LINKS.LWW.
COM/SCJ/A199.
INTRODUCTION
trength training has evolved into
S an activity that is widely practiced
for a variety of reasons. Evidence
suggests that strength training has pos-
itive effects on the musculoskeletal
Address correspondence to Guillermo Escalante,
gescalan@csusb.edu
Copyright
National Strength and Conditioning Association
Copyright ª National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
system as well as in the prevention of
osteoporosis, sarcopenia, lower back
pain, and other disabilities (50). The
benefits of strength training for athletes
have also been well documented (51).
The Centers for Disease Control esti-
mated from a survey given between
1998 and 2004 that nearly 20% of adults
between the ages of 18–65 years old
participate in some sort of resistance
training 2 or more times per week (7).
The increase in the participation of resis-
tance training has naturally led to an
increase in the rates of injuries related
to resistance training (13,20,21,28,37,38).
Injuries to the shoulder complex
account for a large proportion of inju-
ries caused by resistance training
(5,8,13,16,21,25,28,37,38,45). Calhoun
and Fry (5), for example, investigated
injury rates and profiles among elite
powerlifters and found that 17% of their
injuries were to the shoulder region.
Siewe et al. (45) studied injuries and
overuse syndromes in bodybuilders
and reported that 36% of their subjects
reported previous shoulder disorders.
Kolber et al. (25) reported that even
the recreational weight-training popu-
lation may be predisposed to subacro-
mial impingement syndrome because
of some of their specific exercise selec-
tions and techniques.
Strength and Conditioning Journal | www.nsca-scj.com
There are several potential explanations
for the relatively high rate of injuries to
the shoulder complex. The amount of
mobility allowed by the shoulder joint
comes at an exchange of decreased sta-
bility. Evidence also suggests that the
shoulder, which is traditionally a non-
weight–bearing joint, has to assume the
role of a weight-bearing joint during
repetitive lifting (24). Furthermore, re-
searchers have hypothesized that most
weight-training programs emphasize
the strengthening and hypertrophy of
large muscle groups and subsequently
neglect smaller scapular stabilizers
(14,23); this may lead to muscular
imbalances that may eventually predis-
pose weight-training participants to
shoulder injuries. Additionally, common
resistance-training exercises frequently
place the shoulder in injury-prone posi-
tions such as shoulder abduction with
external rotation (12).
The purpose of this article is to pro-
vide the strength and conditioning
professional with knowledge about
the common injuries to the shoulder
complex during resistance training as
KEY WORDS:
bodybuilding; powerlifting; resistance
training; shoulder disorder; shoulder
injury; weightlifting
1
 Exercise Modification Strategies for Shoulder Pain

Table 1
Common strength-training–related injuries to the shoulder (2–4,6,8,10,13,14,16,25,31,33,38,41,42,44,47)

Type of injury Suspected pathology Exercises commonly

associated with injury

Osteolysis of the distal clavicle (weightlifter’s
shoulder) (27)
Soft tissue damage to the rotator cuff (mainly
supraspinatus) and the long head of the biceps
at the shoulder origin inclusive of bursitis, tears,
and shoulder impingement (10,15,35,40,51)
Peripheral nerve injuries such as suprascapular,
long thoracic, and medial pectoral neuropathy
(2,3,33,47)
Anterior shoulder instability, glenohumeral
capsular hyperlaxity, or dislocations (12,16,18)
Bone breakdown at the distal clavicle, widening of 1. Flat bench press (18)
the acromioclavicular joint, subchondral stress
fractures (5,43,44)
Repetitive microtrauma to the tissues from raising 1. Military press
of the shoulder or when the arms are raised
overhead (8)
2. Upright row
3. Side raise (28)
Overtraining, improper technique, direct injury, 1. Military press (33,47)
muscle hypertrophy, and stretch injuries from
end range of motion positions (33)
Positions requiring the humerus to be extended 1. Flat bench press
behind the trunk or that require the shoulder to
be in a position of simultaneous shoulder
abduction and external rotation (40)
2. Behind the neck lat
pull-downs
3. Military press
4. Chest fly (16)
5. Snatch

well as exercises that may predispose
individuals to potential injury due to
the biomechanical demands placed on
the shoulder with these exercises. Fur-
thermore, the article will provide the
strength and conditioning professional
with biomechanical exercise modifica-
tions that will make certain exercises
safer and just as effective at achieving
the goal to strengthen the upper
extremity. Finally, a brief overview
of preventive measures that can be
implemented in a strength and condi-
tioning program for the shoulder will
be discussed. The information in this
article may help the strength and con-
ditioning specialists improve the work
they perform in conjunction with med-
ical professionals in helping athletes
prevent injuries to the shoulder.

TYPES OF SHOULDER INJURIES

Multiple types of injuries have been
reported with strength training. Ac-
cording to Lavallee and Tucker (30),
strength-training injuries can be cate-
gorized as acute nonemergent (i.e.,
muscle strains, ligament strains), acute
emergent (i.e., fractures, dislocations,
and tendon ruptures), and chronic (i.
e., tendinopathies, stress fractures). Evi-
dence suggests that 46–60% of all acute
injuries sustained in strength training
are muscle strains and ligament sprains
(5,22). In the shoulder, various types of
injuries have also been reported with
Figure 1. The “high five” position. This position may make the shoulder vulnerable to injury. resistance training. The prevalence and

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 Table 2
Summary of biomechanical shoulder exercise modifications and alternatives

Exercise Exercise modification (s) Exercise alternative (s)

Barbell bench press 1. Hand spacing no wider than 1.5 times the 1. Reverse grip bench press
biacromial width
2. Place a towel roll or pad 4–6 inches thick on the 2. Decline bench press
chest
3. Use a barbell hand-off from a spotter 3. Use dumbbells
4. Use a modified pressing bar
Dumbell or 1. Avoid excessive horizontal abduction by cuing the 1. Cable fly or cable cross over following the same
machine chest fly athlete to begin the movement with the elbows modification may be used as a progression or
slightly below the shoulders and maintain the alternative to the dumbbell or machine fly version
elbows below the shoulders throughout the
movement
2. Cue the athlete to only horizontally abduct their 2. Place the athlete supine on the floor to perform
shoulders so that the elbows are to their mid or this exercise to limit range of motion
posterior trunk at the bottom of the movement
Barbell military 1. Place the hands and elbows anterior to the 1. Use dumbbells following the recommended
press shoulder modification
2. Use machine overhead press following the
recommended modification
Behind the neck lat 1. Lat pull-down to the front 1. Modified lat pull-down to the front (see text for
pull-down explanation)
2. V-Bar lat pull-down
3. Underhand lat pull-down
Lateral raise 1. Stay below 908 of shoulder abduction 1. Scaption lateral raise with the arms externally
rotated (thumbs up) in a plane 308 anterior to the
frontal plane
2. Avoid internally rotating the humerus during the
movement
Upright row 1. Bring the bar up to the nipple line or through 1. Use dumbbells following the recommended
a pain-free range of motion modification
Snatch 1. Not Applicable 1. Power clean
2. Hang clean

types of injuries observed in strength
training are typically dependent on
the exercise selection and load used
by different strength-training programs
(30). Table 1 summarizes some of the
common shoulder injuries as a result of
strength training that have been re-
ported in the literature.
SHOULDER EXERCISES WITH A
HIGH RISK OF INJURY
Some commonly performed strength-
training exercises may place the
shoulder at risk. Specific exercises that
have been associated with injuries to
the shoulder are identified in Table 1.
Several authors discuss exercises that
place the shoulder joint in the “high
five” position as potentially hazardous
to the shoulder joint because of the
increased stress placed on the anterior
shoulder (12,14,24,26). The “high five”
position is defined as the shoulder in
908 of external rotation simultaneously
with 908 of shoulder abduction (Fig-
ure 1). Repeatedly placing the shoulder
in this “high five” position with heavy
loads may contribute to hyperlaxity
or instability to the static glenohum-
eral ligamentous-capsular restraints
(14,24,26). Jobe and Kvitne (19) sug-
gested that when increased laxity or
instability occurs at the shoulder, the
dynamic rotator cuff muscles likely
exert a greater force to stabilize the
humeral head. This repetitive dynamic
compensation of the rotator cuff may
result in fatigue followed by tendinosis
and pain in the rotator cuff.

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 Exercise Modification Strategies for Shoulder Pain
Figure 2. Wider grip bench press. When the hands are placed greater than 1.5 times
the biacromial width, there is more demand on the rotator cuff and the
biceps tendon. Notice that the shoulder approaches 908 of abduction.
There are other commonly performed
resistance-training exercises that may
place the shoulder joint at risk. Reeves
et al. (37,38) suggested that exercises
placing the shoulder in a position of
extension past the trunk could
also contribute to anterior shoulder
instability and rotator cuff injuries. Sim-
ilarly, Haupt (16) associated osteolysis
of the distal clavicle with the bench
press during the eccentric phase of
the exercise when the shoulder is
extended posterior to the trunk due
to the repeated microtrauma at the
acromioclavicular joint.
Other exercises that may predispose
the shoulder to injury are those in
which the shoulder is internally rotated
during shoulder abduction (e.g., lateral
deltoid raises). In a study investigating
characteristics of shoulder impingement
in the recreational weight-training
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population, Kolber et al. (25) concluded
that avoiding the performance of the
upright row and lateral deltoid raises
beyond an angle of 908 of shoulder
abduction could potentially reduce the
likelihood of sustaining shoulder
impingement. Hawkins and Kennedy
(17) reported if the shoulder is internally
rotated during scapular elevation, the
greater tuberosity of the humerus im-
pinges the rotator cuff tendons and
bursa against the acromion.
BIOMECHANICAL SHOULDER
EXERCISE MODIFICATIONS AND
ALTERNATIVES
To successfully strengthen and hypertro-
phy the muscles of the upper body with-
out predisposing athletes to shoulder
injury, it is important for the strength
and conditioning professional to provide
athletes with safer exercise alternatives
that are effective in achieving the
athlete’s goals. Furthermore, if athletes
are recovering from a shoulder injury
the strength and conditioning profes-
sional should be able to provide the ath-
lete with pain-free range of motion
exercises or exercise modifications that
will facilitate their return to a normal
level of function; this should be accom-
plished in conjunction with other medi-
cal professionals such as certified athletic
trainers, physical therapists, or physi-
cians. Understanding the underlying bio-
mechanics of the shoulder will help the
strength and conditioning professional
provide appropriate guidance to athletes.
Table 2 provides an overview of effective
exercise modifications or alternatives
that still target the appropriate muscula-
ture with less stress on the commonly
injured shoulder structures.
THE BENCH PRESS
The bench press is a commonly per-
formed exercise among athletes that is
often used as a 1 repetition maximum
to assess upper extremity strength.
Although there are benefits that can
be gained from this compound exercise,
the risks described in the previous sec-
tion may contribute to shoulder injuries.
To reduce the risks, several exercise
modifications and exercise alternatives
exist to make the exercise safer.
Alternating the spacing of the hands
from a wider grip to a grip, no wider
than 1.5 times the biacromial width
(Figures 2 and 3) has been suggested
to reduce the peak torque in the press-
ing motion and thus reduce the
demand placed on the rotator cuff
and the biceps tendon to stabilize the
head of the humerus (15,49). The
closer hand position has also been sug-
gested to allow the athlete to keep the
shoulder abducted to less than 458
throughout the range of motion as well
as prevent it from exceeding 158 of
shoulder extension when the bar rea-
ches its lowest point (12). The alter-
ation in the amount of shoulder
abduction from the closer hand place-
ment allows the clavicular border of
the pectoralis major and the biceps bra-
chii muscles to gain a mechanical
advantage to aid in shoulder flexion
through the initial and middle range

Figure 3. Closer grip bench press. When the hands are placed less than 1.5 times the
biacromial width, there is less demand on the rotator cuff and the biceps
tendon. Notice that the amount of shoulder abduction is less than 458.
of motion; furthermore, a decrease in
stress occurs on the long head of the
biceps muscle at the bicipital groove as
Figure 4. The bench press with no towel or pad. When the shoulder extends beyond
the plane of the body, there is a higher risk for injury.
the shoulder moves into horizontal
adduction (1,12,29,36). In addition to
these benefits, the literature has suggested
that keeping shoulder abduction below
458 reduces the compressive forces at
the distal clavicle and alters the touch
position at the bottom of the movement
to a point more superior to the xiphoid
process that reduces the net torque on
the shoulder (12,15,32).
Another effective modification reported
in the literature to reduce the stress on
the shoulder during the bench press is
placing a towel roll or pad 4–6 inches
thick over or under the shirt (Figures 4
and 5) while performing the exercise
(11,12). Performing this modification
provides a visual and tactile cue to the
athlete as to the distance the bar should
travel during the eccentric portion of
the movement. Furthermore, it prevents
the shoulder from extending past the
trunk which has been suggested as
a movement to avoid to decrease inju-
ries to the rotator cuff and acromiocla-
vicular joint as well as reduce anterior
instability (16,37,38).
Using a barbell hand-off from a spotter
is another strategy that may be imple-
mented to help reduce the likelihood
of injuries to the shoulder. The litera-
ture suggests that the hand-off should
be used for every set performed for the
bench press, inclusive of warm-up sets
(12). According to Fees et al. (12), the
barbell hand-off may reduce the risk of
shoulder subluxations or dislocations
during the removal or return of the
bar back to the rack position.
Various exercise alternatives or varia-
tions may also be implemented that
target the musculature in a similar
fashion. One example is the underhand
grip (reverse grip) bench press where
the hands are on the bar in a fully supi-
nated position (Figure 6). This exercise
places the shoulder in a position of rel-
ative external rotation which subse-
quently puts the long head of the
biceps tendon under the acromion
and rotates the supraspinatus muscle
posteriorly away from the acromion
(12,35). Conversely, the traditional
overhand grip bench press places the
shoulder in a position of relative inter-
nal rotation and places the biceps
tendon out from under the acromion

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 Exercise Modification Strategies for Shoulder Pain

while positioning the supraspinatus

directly under the acromion (9,12).
Despite the biceps tendon being placed
away from the acromion, the full fore-
arm pronation of the overhand bench
press stresses the attachment of the
long head of the biceps during the
exercise (12). It is also important to
comprehend that if a structure is
directly under the acromion, it is
potentially at risk from mechanical
abrasion if the athlete has a hooked
(type III) acromion (12) or if the struc-
ture itself is inflamed.
Another exercise alternative is the use
of the decline bench press. Durall et al.
(11) and Fees et al. (12) both reported
Figure 5. The bench press with a towel or pad. The shoulder does not extend beyond
the plane of the body and may decrease injuries to the rotator cuff,
that throughout the movement of
acromioclavicular joint, and the anterior shoulder structures. a decline press, the shoulder is kept
in a safe position below 908 of flexion
and 458 of abduction with neutral
external rotation. Unlike the decline
bench press, the incline barbell bench
press should be prescribed with cau-
tion as the “high five” position is main-
tained throughout the exercise and
increases the strain on the anterior
middle and anteroinferior glenohum-
eral ligaments (12,14,34). Athletes with
anteroinferior shoulder instability
should perhaps consider avoiding this
exercise all together.
The modified bench press bar (Figure 7)
provides another alternative method to
perform the bench press. The modified
bench press bar allows the shoulder to
be kept in a position of approximately
458 of abduction which provides the
same benefits as described with the
closer hand placement of the barbell
bench press. One of the advantages of
the modified bench press bar over the
traditional barbell is that the hand and
wrist maintain a more neutral position
and remain in alignment of the forearm
and the humerus throughout the move-
ment. Furthermore, this movement pat-
tern is more specific to sports such as
football where offensive linemen block
defensive players in a plane similar to
that provided by the modified bench
Figure 6. The reverse grip bench press. This exercise places the shoulder in a position
press bar.
of relative external rotation which subsequently puts the long head of the
biceps tendon under the acromion and rotates the supraspinatus muscle Using dumbbells is another alternative
posteriorly away from the acromion. to using a barbell for chest pressing

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 motions. Dumbbells allow the athlete
more freedom in terms of finding
a pain-free range of motion. Hence, it
is easier to avoid at risk positions such
as the “high five” position with the
dumbbells than with a barbell. Because
of the increased control the athlete has
with dumbbells, Durall et al. (11) rec-
ommended using them as a potential
alternative even in a relatively higher
risk exercise such as the incline press.
Evidence suggests that using dumb-
bells instead of barbells may require
individuals to control and balance the
weights independently and potentially
alter the involvement of the agonists,
synergists, stabilizers, and antagonists
(39). Both Welsch et al. (48) and Sae-
terbakken et al. (40) reported similar
electromyographic (EMG) activity in
the pectoralis major and anterior
Figure 7. The modified bench press bar. The shoulder is kept in a position of
approximately 458 of abduction which decreases the demand of the rotator
cuff and biceps tendon. The hand and wrist also maintain a more neutral
position that is easier on the wrists.
Copyright ª National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
deltoid in dumbbell chest presses com-
pared with barbell although dumbbell
loads were 63–83% of the barbell loads.
Because lighter loads may be used with
dumbbells without hindering EMG
activity in the target musculature as
compared with using a barbell, this
could prove to be advantageous to
those athletes returning from an injury.
THE CHEST FLY
The chest fly is an exercise commonly
performed to target the chest and ante-
rior deltoid musculature. Similar to the
bench press, lowering the shoulder past
the trunk of the body should be
avoided to decrease injuries to the rota-
tor cuff and acromioclavicular joint as
well as reduce instability to the anterior
shoulder structures (16,37,38). Durall
et al. (11) suggest that excessive
Strength and Conditioning Journal | www.nsca-scj.com
horizontal abduction should be avoided
when performing this exercise to avoid
stress to the anterior capsule. To accom-
plish this, cueing the athlete to lower
their elbows to their mid or posterior
trunk at the bottom of the movement
could prove to be an effective strategy
(Figures 8 and 9). If the athlete requires
a tactile cue to successfully avoid exces-
sive horizontal abduction, the athlete
may be placed supine on the floor to
perform the exercise so that the floor
serves as the tactile cue when the el-
bows make contact with the floor. Du-
rall et al. (11) recommend that the
elbows should be kept inferior to shoul-
der level to reduce shear across the sub-
acromial space (which may irritate the
rotator cuff tendons and bursa); they
suggest to advise the athlete to begin
the movement with the elbows slightly
inferior to the shoulders and maintain
the elbows in that position throughout
the movement.
Another exercise alternative is to per-
form the exercise with adjustable cable
pulleys in place of dumbbells or
a machine. Unlike dumbbells, the ca-
bles provide a constant level of tension
throughout the range of motion yet
provide various range of motion angles
because the exercise can be performed
in standing at various body and shoul-
der positions or on a bench in a similar
position as the dumbbell fly. The vari-
ous shoulder angles and body posi-
tions available with the adjustable
cable pulleys for the chest fly exercise
can help the strength and conditioning
professional to identify pain-free range
of motion movements for the athlete
for this exercise that also avoid high-
risk shoulder positions such as exces-
sive horizontal abduction and the “high
five” position.
THE BARBELL MILITARY PRESS
The overhead (military) shoulder press
is an exercise that is sometimes per-
formed behind the neck (Figures 10
and 11). The behind the neck version
of the exercise places the shoulders in
the risky “high five” position. To avoid
this position, Durall et al. (11) recom-
mend to instruct the athlete to maintain
7
 Exercise Modification Strategies for Shoulder Pain

sometimes performed by athletes and

Figure 8. Chest fly with the elbows horizontally abducted past the trunk of the body.
When the shoulder extends beyond the plane of the body, there is
a higher risk for injury to the shoulder.
the hands and elbows anterior to the
shoulder during the movement when
using either barbells or dumbbells. If
a shoulder press machine does not
allow the athlete to keep their hands
and elbows anterior to the shoulder,
Durall et al. (11) suggest to place the
athlete facing backward on the seat to
avoid the “high five” position.
Dumbbells are also a good alternative
for the shoulder press. Similar to the
chest press, the use of dumbbells offers
the advantage of more freedom to find
a pain-free range of motion. Further-
more, Saeterbakken and Fimland (39)
reported increased neuromuscular
activity in the deltoid muscle using
dumbbells over barbells in the shoulder
press despite the dumbbell shoulder
press having a lower 1 repetition max-
imum strength value as compared with
the barbell shoulder press.
THE LAT PULL-DOWN
Similar to the shoulder press, the behind
the neck variation of the lat pull-down is
potentially places the shoulders at risk
due to the stresses placed on the shoul-
der with the “high five” position. Instead
of performing this exercise behind the
neck, the lat pull-down to the front is
a viable alternative. Sperandei et al. (46)
reported that the EMG activity of the
target muscle (latissimus dorsi) was the
same when performing the exercise
behind the neck compared with the
front and concluded that the pull-
down to the front is a better choice.
Furthermore, they suggested that the
V-bar lat pull-down, which places the
hands in a close grip position with
a neutral grip, could be used as an alter-
native exercise.
Another lat pull-down variation reported
in the literature is the modified lat pull-
down to the front (Figure 12). Fees et al.
(12) described the modified seated lat
pull-down where the torso is reclined in
308 of trunk extension and the bar is sus-
pended at arms’ length in line with the
xiphoid process. Using a grip of 1.25–1.5
times the biacromial width, the bar is
pulled from overhead to slightly above
the xiphoid process in the sagittal and
coronal planes. Fees et al. (12) suggest that
this modified version of the lat pull-down
to the front places a greater emphasis on
the scapular retractor and latissimus dorsi
muscles as compared with the behind the
neck variation of the exercise.
The underhand (supinated) grip lat
pull-down is another alternative to
the behind the neck lat pull-down.
The supinated grip, as previously dis-
cussed, puts the long head of the
biceps tendon under the acromion
and rotates the supraspinatus muscle
posteriorly away from the acromion
(12,35); hence, it may be a good alter-
native for those athletes recovering
from primary shoulder impingement
syndrome. Fees et al. (12) recommend
implementing this exercise as part of
a pain-free range of motion progression
to lead to a front lat pull-down.

THE LATERAL RAISE AND

Figure 9. Chest fly with the elbows horizontally abducted to the plane of the body. UPRIGHT ROW
When the shoulder does not extend beyond the plane of the body, there is The lateral raise and the upright row
a decreased risk in injuries to the anterior shoulder. are excellent exercises to strengthen

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Figure 10. The behind the neck military press. This exercise places the shoulder in the
at risk position.
the middle deltoid, supraspinatus, and
the upper trapezius. Because the tradi-
tional performance of these exercises
require simultaneous elevation and
internal rotation of the shoulder as
the arm goes to shoulder level and
beyond, the greater tuberosity of the
humerus may impinge the rotator cuff
tendons or the subacromial bursa
against the acromion (17). The repeti-
tive nature of this movement may lead
to shoulder impingement or tears to
the rotator cuff. Kolber et al. (25) inves-
tigated the characteristics of shoulder
impingement in the weight-training
Figure 11. Military press to the front. This safer alternative keeps the shoulders in
a safer plane throughout the movement.
Copyright ª National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
population among 77 men and re-
ported that a significant association ex-
isted between clinical characteristics of
shoulder impingement and performing
the lateral deltoid raise and the upright
row above 908 of shoulder abduction.
In prescribing these exercises with
asymptomatic individuals, the strength
and conditioning professional may cue
athletes to keep the shoulder below the
908 mark of shoulder abduction during
the exercises (Figures 13 and 14).
In athletes recovering from shoulder
impingement or other rotator cuff
pathology, strength and conditioning
Strength and Conditioning Journal | www.nsca-scj.com
coaches may opt to instruct athletes
to eliminate the upright row altogether
and to substitute the traditional lateral
raise exercise with the movement in
the scapular plane (308 anterior to the
frontal plane) with the shoulders exter-
nally rotated (Figure 15) in an effort to
maintain the size of the subacromial
space during the motion (43).
OLYMPIC-STYLE LIFTS
The snatch and the clean and jerk are
weightlifting exercises prescribed by
strength and conditioning coaches to
help improve power output with their
athletes. Although these are excellent ex-
ercises, it is important to note that the
ballistic nature of the movements creates
a potential hazard for the athlete.
Because the exercises require the athlete
to accelerate the weight quickly while
generating maximum power and veloc-
ity, this can place the athlete at risk. Le-
vallee et al. suggest that the jerking and
rotational movements of these lifts may
cause dislocations, tendon ruptures, and
fractures (30). Furthermore, Lavalleee
et al. suggest that when the shoulder is
placed in the “at risk” position of extreme
shoulder flexion and abduction, such as in
the snatch, rotator cuff injuries or support-
ing musculature strains may occur (30).
To avoid the “at risk” position of the
shoulder all together, the power clean,
the hang clean, and the high pull (to just
below 908 of shoulder abduction) are
good alternatives to the snatch and the
jerk to develop power without placing
the shoulder in the “at risk” position.
With athletes recovering from rotator
cuff tendinosis or subacromial impinge-
ment, the strength and conditioning
coach may want to start the athlete with
a kettlebell swing where they can prac-
tice the triple extension component of
the movement without having to put
the shoulder in the upright row position
during the execution of the power clean
or the power clean derivatives. These
modifications are easy to implement for
both the athlete and the strength coach.
PREVENTIVE STRATEGIES FOR
SHOULDER INJURIES
In an effort to avoid injuries to the
shoulder, the strength and conditioning
9
 Exercise Modification Strategies for Shoulder Pain

range of motion in shoulder flexion,

Figure 12. The modified lat pull-down. This modification of the exercise has been
suggested to place a greater emphasis on the scapular retractor and latissimus
dorsi muscles as compared with the behind the neck variation of the exercise.
professional should be familiar with
predisposing factors that may put
strength-training athletes at risk.
Figure 13. The lateral raise to 908 of abduction. Raising the arms to no more than 908
of shoulder abduction may decrease the risk of shoulder impingement.
Kolber et al. (23) reported that recre-
ational weight-training participants
had decreased mobility for active
abduction, and internal rotation as
compared with controls who did
not participate in resistance training.
Conversely, weight-training partici-
pants had increased active range of
motion for shoulder external rotation
as compared to the control group.
Furthermore, the weight-training par-
ticipants had greater posterior shoul-
der tightness and larger agonist to
antagonist muscular imbalances as
compared to the control group.
Kolber et al. (23) reported that the
findings in their investigation suggest
that the recreational weight-training
population is predisposed to strength
and mobility imbalances that have
been associated with shoulder disor-
ders. The authors suggested that rec-
reational weight-training participants
may bias their training toward the
larger muscle groups such as the pec-
toralis or deltoids and neglect the
smaller muscle groups such as the
scapular stabilizers and rotator cuff
that are responsible for stabilizing
the scapula and rotating the gleno-
humeral joint; this likely contributes
to the imbalances observed. Evidence
of these imbalances and their propen-
sity to contribute to shoulder pathol-
ogy have been reported among
weight-training participants with sub-
acromial impingement (27). A shoul-
der screening process for coaches to
use with athletes to assess an athlete’s
suitability for overhead lifting exer-
cises as recommended by Howe and
Blagrove (18) is a tool to use in order
to help prevent shoulder injuries.
Furthermore, it is recommended that
the strength and conditioning coach
implement exercises that target the
lower trapezius, middle trapezius, ser-
ratus anterior, and external rotators to
improve the balance between the
larger muscle groups and the smaller
stabilizing muscles. Additionally,
stretching exercises that address pos-
terior shoulder tightness such as
stretching the shoulder into internal
rotation and stretching of the poste-
rior shoulder capsule could prove to
be beneficial.

10 VOLUME 0 | NUMBER 0 | MONTH 2016

Copyright ª National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 predispose them to injuries. Once
these imbalances are located, the
strength and conditioning coach
should prescribe appropriate exer-
cises to help correct the imbalances
and ensure that training is well-
balanced between the larger muscle
groups and the smaller stabilizing
muscles of the shoulder region so
that the likelihood of injuries is
decreased. If an athlete is recovering
from a shoulder injury, it is essential
that the strength and conditioning
coach to work closely with the med-
ical staff to ensure there is continuity
of care among all members of the
sports medicine and sports perfor-
Figure 14. The upright row to lower-/mid-chest line. Modifying the range of motion mance enhancement personnel.
of this exercise to mid-chest helps to keep the shoulder to no more than Conflicts of Interest and Source of Funding:
908 of shoulder abduction and may decrease the risk of shoulder The author reports no conflicts of interest
impingement.
and no source of funding.

CONCLUSION AND PRACTICAL to certain exercises can help the

APPLICATIONS
The shoulder is a complex joint that
sacrifices stability for a great amount
of mobility. The repetitive nature of
strength training, along with the
compromising positions in which
the shoulder is placed in many tradi-
tional strength-training exercises,
makes the shoulder joint susceptible
to a variety of injuries. Understand-
ing the biomechanical modifications
strength and conditioning coach Guillermo
become better prepared to assist ath- Escalante is an
letes in avoiding injuries to the shoul- Assistant Profes-
der as well as assist athletes in sor of Kinesiology
recovering from shoulder injuries. It at California
is recommended that strength and State University
conditioning coaches provide appro- San Bernardino.
priate screening for athletes before
initiating overhead activities that
may help to find mobility and
strength imbalances that may

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