Today’s post is an amazing guest post from two of my colleagues at Champion, Dave Tilley and Dan Pope. It’s really an honor to get to work with these guys everyday, as they are some of the brightest minds in the performance therapy and training industry right now. They recently release an educational product that I recommend everyone check out called Peak Shoulder Performance, learn more about it below, plus take advantage of a special discount for my readers!
We are very fortunate to work at a facility that is on the cutting edge of shoulder rehabilitation and sports performance. As a team at Champion, we have combined our ideas in a collaborative format to innovate some of the most effective methods for optimal shoulder training.
We have also been very fortunate that our professional work has given us first-hand experience helping a very diverse population of clients for shoulder-related issues. We have been lucky to see the systems we’ve created at Champion successfully help clients with shoulder injuries who are Division 1 and professional athletes, elite gymnasts, internationally competitive Olympic weightlifters, CrossFit games competitors, power lifters, and some of the most intense general population fitness enthusiasts out there. We can be very honest in saying that these people push their shoulders to the absolute limit with training and competition.
We mention these things not to seem egotistical or to brag. It is to highlight that a properly designed rehabilitation and performance program can get someone back to the highest level of training in sports.
The 5 Biggest Mistakes People Make Returning to Training After a Shoulder Injury
With this being said, we have found helping someone return to these highly demanding training environments following a shoulder injury is one of the trickiest areas to navigate. The knowledge our mentors have taught us and the experiences working with clients at Champion has given us some great insight to this challenge. We’ve experienced what works, what didn’t, and what really derails people when trying to get back to the training they love. In an effort to help readers out, here are five of the most common errors we see made when trying to return back to training following shoulder injury.
1. Rapidly Increasing Workload When Pain is Gone, or When Athletes are “Cleared”
This is without a doubt the most common error we have made as younger clinicians, and see others make regularly. Nothing is more exciting than when an athlete comes into the clinic saying they have been pain-free or got cleared by a doctor to train. However, we have to be very cautious about how much work we allow people to return to following shoulder injury.
Maybe you’ve heard clients say this:
“My shoulder was feeling much better so I jumped back into training. My pain has flared up again pretty bad. What happened?”
Yikes, not fun. We’ve had that stomach dropping moment more times than we care to admit. But, these things happen and it’s how we learn. With that said, it often feels like a problem that could have been avoided.
To help with this, we recommend you educate clients early in the rehabilitation process. Once you start feeling better, it’s not time to return to training full on. Things may be feeling great, but we still need to follow the continual game plan of progressive loading.
Start with the educational process, and then implement an objective plan of attack for rehabilitation. Things to keep in mind are the basic shoulder demands seen in a traditional training program. Things like vertical pushing and pulling, horizontal pushing and pulling, rotator cuff maintenance care and dynamic stability all come to mind. The plan must be outlined well in advanced and must take into account goals, timelines, and mild fluctuations in progress. If we plan and execute fully on this plan we can avoid athletes having flare up when they return to training.
2. Not Restoring Unilateral Strength Symmetry Before Bilaterally Loading The Shoulder
Everyone is going to have a dominant arm, and many sports require asymmetry for success (throwing sports come to mind). With that said, we see clients every week at Champion who continue to have shoulder pain because they failed to regain the most basic foundation of unilateral shoulder strength and stability before jumping back to training. Must people want to jump back into more fun exercises like bench pressing, pull ups, and push-ups before restoring symmetry.
We have to remember that with almost all shoulder injuries or pain comes protective inhibition and some degree of minor disuse atrophy. The severity of strength loss ranges widely based on the nature and severity of the injury. This is without considering that there may have been unilateral imbalances (right to the left) or training imbalances (push to pull ratios) that may have contributed to the injury in the first place.
At Champion, for athletes that are not asymmetrically biased, we like to see an objective 85% – 90% symmetry index for their baseline strength before progressing to advanced bilateral shoulder exercises in training. Sometimes we do this with dynamometers for basic strength. Other times we follow more multi-joint exercise comparisons for single arm floor presses, single arm pulldowns, single arm bent over rows, and 1/2 kneeling presses. If someone can single overhead press 40lbs for five reps on their uninvolved shoulder but struggles to get five clean repetitions with 20lbs on their involved side, returning to a bilateral barbell press may not be the best route at that time.
There is large variability based on the injury, athlete, and sport, but we suggest trying to write programs that close the gap and then focus in on more progressions. Again, it can save a lot of headaches down the road.
3. Treating the Cause of Shoulder Pain, Not Only The Site of Pain
This is very cliché in the Sports Medicine world, but remains extremely important. As Brandon Buchard says, “Just because it is common knowledge, doesn’t mean it is common practice.”
Before creating a return to a training program for a client, ask yourself,
“Have I considered all of the variables that may have contributed to this shoulder injury in the first place.”
Common overlooked factors include workload ratios, technique, programming, problems in joints adjacent to shoulder joint (lumbopelvic, thoracic, elbow), necessary baseline range of motion, strength, and exercise selection.
Now, there may be too many factors to address at once. Some factors may be out of your control. With that said as medical providers, athletes, and sport coaches we should try to tackle as many as we can. We should aim to educate the client as much as possible. Prioritize the main issues and have an open conversation with the client, parent, or coach for why addressing these issues is so important for both performance and re-injury risk. This drastically helps minimize a recurring problem snow balling down the road.
4. Medical Providers Not Creating Individualized, Objective, Return to Fitness Programs
This point goes in line directly with number one. Without a detailed roadmap for getting back to training goals, athletes often feel scattered and overwhelmed. I have found the best method is to start with a conversation on the primary goals or when the athlete desires to be back to sport. From that date, you can reverse engineer the progressions in training needed to aim for that end goal. Once the timeline is established, you can create a progression of exercises, sets, repetitions, and metabolic work in a periodized fashion. Here is a simplified example I use all the time at Champion
Goal: Pain-Free Body Weight Pull Ups in 2 months
Week 1 & 2:
- Half kneeling single band pulldowns with bent elbow
- 4×10, 2x/week, with 3-second eccentric tempo
- Starting in 150 degrees of shoulder elevation and progressing to full 170 of shoulder elevation
Week 3 & 4:
- Kneeling single arm Kieser or Weight Stack Pull Downs with bent elbow
- 4×8, 2x/week, with 3-second eccentric tempo
- Once 90% symmetry established, switch to bilateral Keiser/Weight Stack Pull Downs
Week 5 & 6:
- Self-spotted pull-ups, standing on box for lower body assistance as needed
- 5×5, 2x/week, focusing 1 second top and bottom hold
Week 7 & 8:
- Progression to appropriate band assistance for 5×5, 2x/week
- Reducing assistance until light or no band is needed
The exercises, sets, reps, and progression rate can be adjusted based on the injury type, client, and training age. Educate clients that the initial program you write is just the first attempt, and that you may need to adjust on the fly based on good or bad days. There may be small amounts of pain, but we personally tell people no more than a 3/10 and it can’t last for more than 24 hours.
Remember it’s less about the specific exercise prescription, and more about understanding the principles underlying the goal the client says they have. Doing this for the primary movements can be extremely helpful for the client and help you design a better program.
5. Not Continuing Basic Soft Tissue and Cuff Care for Maintenance
This is another shockingly common problem that comes up following successful reintegration to training. Athletes and coaches must remember that just because there is no pain, doesn’t mean you’re back to full function. As athlete’s train more they naturally acquire soft tissue stiffness, fatigue, and imbalances around their shoulder joint. This is variable based on the repetitive activates they are doing. Most commonly, we see the latissimus dorsi, teres major, pecs, upper trap, and subscapularis as culprits that cause losses in basic range of motion. Letting this slowly creep up is an easy way for pain to creep back in.
We must be dedicated to regular soft tissue management, strength balance work and high-level cuff strength. This is for a very similar reason as above. The more athletes tend to train, the more they focus on larger primary muscle groups and miss the same amount of development for their smaller stabilizers. When this imbalance creeps up it may create a situation for injury.
In an ideal world, the importance of this has been explained to the client and they maintain visits coming to see you as a provider. Manual therapy, hands-on strength work, and tweaking programs based on changes are incredibly helpful for athletes to get the most out of their shoulders. We are proud to have a lot of athletes realize the importance of this and continue to come on a bi-weekly or monthly basis for tune-ups.
Bonus – Lack of Communication Between All Parties
Open communication with parents, sport coaches, trainers and physicians is essential for athletes returning back to sports. Everyone needs to be on the same page with the athlete’s rehab. If any link in this chain is broken, athletes can be left frustrated and injuries can linger around. Having this communication ensures the bridge back to performance is successful and each professional is doing their part for the athlete.
If the athlete is an individual competitor, the most critical communication is between yourself and the athlete. The more transparent you can be, and the more open you are to answering athlete questions, the better.
Never be afraid to answer questions or concerns that come up. Be honest about the reality of ups and downs for returning to training, and also the possible positive or negative outcomes that come with big decisions. Discussing timelines, pain levels, proactive exercises, and prognosis can really ease the athletes mind and help them establish high levels of trust with you.
For what it’s worth, we have found that the higher the level of the athlete, the more they value honest and open communication. High level athletes are just people, and really appreciate the down to earth professionals who have their best interest in mind above all else.
Peak Shoulder Performance: The Ultimate Guide to Getting Out of Pain and Returning to High Level Fitness
If you enjoy this information, we’re happy to say it’s just the tip of the iceberg on how we approach returning to training after a shoulder injury. If you want to learn exactly how we return athletes back to high level fitness after a shoulder injury, be sure to check out our recently released online course that has been very well received.
We dive deep into the exact exercise progressions, principles, and maintenance care we use on athletes every day. This course is intended to help athletes themselves, medical providers, and coaches better understand this often-frustrating topic.
We know this information can help a lot of people, so we are going to offer a monster deal and chop off $50 from the original price just for Mike’s readers this week. Check out the link below to learn more, and enter “Reinold50” to cash in on the discount, good for this week only! Offer ends Friday 3/9/18 at midnight EST:
Dan Pope DPT, OCS, CSCS, CF L1
CEO of Fitness Pain Free
Dave Tilley DPT, SCS, CSCS
CEO of SHIFT Movement Science