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The 5 Biggest Mistakes People Make Returning to Training After a Shoulder Injury

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”

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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

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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

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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

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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

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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

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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

Peak Shoulder Performance coverIf 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

Get in Shape in 2012

Each year around this time I offer an article about fitness to help those with New Year Resolutions and those that want to get in shape in 2012.  I like to update this every year as trends in fitness are constantly changing.

Why You Need to Get in Shape in 2012

I discussed this in last year’s article on How to Become Healthier, Richer, and More Attractive, but the numbers are real and worth reiterating.  Recent reports are stating that close to 75% of Americans will be overweight by 2015.  That is completely insane.  I’m going to take this directly from Men’s Health editor David Zinczenko in his new book The New Abs Diet (which I still love and you should read more about here), but here are some startling facts if you are overweight:

  • 50% more likely to develop heart disease
  • 360% more likely to develop diabetes
  • 31% more likely to die of any cause
  • 120% more likely to develop stomach cancer
  • 590% more likely to develop esophageal cancer
  • 35% more likely to develop kidney cancer

But for some reason, these numbers don’t scare us enough, maybe these next two will since no one seems to care about their health, lets focus on what really motivates us – money and…  well, you know:

  • 14% less attractive to the opposite sex
  • 37% more in expenses for prescription drugs
But there is hope.  Exercising a small amount each day has been shown to:
  • Reduce mortality by 14%
  • Reduce chance of cancer by 10%
  • Reduce chance of cardiovascular disease by 20%

So in a nutshell, getting in shape in 2012 will allow you be healthier, richer, and more attractive.  Where do we start???

Home Workouts

Like I do each year, I will start this section off by saying that I fully encourage people to go to a gym and work with a qualified personal trainer or strength and conditioning specialist.  There is NO DOUBT in my mind that this is ideal and will provide much better benefits than any home workout.  That being said, this section isn’t geared towards people that want to do that, it is geared towards everyone else.  Realistically, I know that there is a large percentage of our population that simply can’t or will not do this, so encouraging home workouts is an option for them.

In the past, I have discussed the best home workout programs and included such staples as P90X, Mark Verstegan’s Core Performance series, and Yoga (click the link earlier to read more).  I still like all of these programs but there are three programs that have been on the market since I originally published this article in 2008 that are worth mentioning.

Eric Cressey’s Show and Go Training

Show and Go TrainingI have always kept the target of these articles to programs that can be conducted at home, however Eric Cressey has released his Show and Go Training program that anyone can use on their own.  Unless you have a sweet gym in your basement or garage, you will need to get to a gym to perform these workouts.  However, this is the next best thing to working one on one with a fitness specialist.  Eric shares his acclaimed training programs and provides a comprehensive program that any can follow and any can benefit from.  This is the next step program that many of us are probably looking for to narrow the gap between a home workout like P90X and a real strength and conditioning program.

Click here for more information on Eric Cressey’s Show and Go Training.

P90X2

P90X2The sequel to the original and has 12 new workouts.  I really enjoyed the original P90X programming and thought they did a good job with the production of the DVDs.  P90X2 is even better.  This time around, they took feedback from the millions of P90X users and combined it with more modern science and fitness research.  I like the added focus on recovery and mobility in this new series.  Like the original P90X, P90X2 is a very thorough program.  You won’t get bored quickly and you will be challenged.  You may still probably mute the DVDs and play your own music once you are familiar with the programs!

Click here for more information about P90X2.

Insanity

I have to mention it, but P90X has had a competitor the last few years called Insanity.  I’ve taken a look at the program and it is pretty intense.  I love the marketing as well and have to admit, we tried throwing the words “insanity” and “extreme” around in rehab but it just doesn’t work as well when I tell someone to perform their “Extreme Shoulder Program” or “Range of Motion Insanity” program.  If you truly do not want to go to the gym, then P90X and Insanity may be options for you, but the programs are not quick and easy, the both have nearly daily workouts between 60-90 minutes.

Click here for more information about the Insanity workout.

Jillian Michaels

Jillian Michaels

I have to mention that Jillian Michaels can basically sneeze on a napkin and turn it into a well selling workout at this point.  One of the fitness specialists from the Biggest Loser TV show, Michaels has turned herself into a huge fitness business.  She has more DVDs out right now than I can even count, but what may be even more impressive is how many different sports bras she owns.  She is hot right now and has such a variety of home base workout programs that you should be able to find one that fits your goals.  I must admit that I cringe every time I watch the biggest loser and see the workouts they perform, so take popularity with a grain of salt.

Click here for more information on all of Jillian Michaels’ DVDs.

Home Workout Equipment

My original article on the best home workout equipment include items like the Perfect Push Up, Yoga Equipment, and the Bowflex SelectTech Weight System.  Still great products and worth pursuing.  Last year I discussed the TRX Suspension Training system.

TRX Suspension Training and the TRX Rip Trainer

TRX Rip Trainer

I really love the TRX Suspension Trainer.  Over the summer, I published a video of a new exercise I called TRX Serratus Slides to strengthen the serratus anterior.  This is just a small example of how I use the TRX Suspension System in rehab, but the programs that come with the TRX products can form a very good home workout program with minimal equipment.  Eric Cressey and I show a few techniques with the TRX products during our Functional Stability Training of the Core program as well.

TRX now has a new product called the TRX Rip Trainer, which is essentially a bungie cord at the end of a long dowel.  Like all of the TRX products, the Rip Trainer’s production quality is top notch.  TRX really does a great job putting together a great product with a great workout program included.  The Rip Trainer can be used to perform many home exercises including chops and lifts that traditionally require a Keiser or Pulley machine.  There are bunch of new uses that I come up with everyday as well.

I recommend both the TRX Suspension Training System and TRX Rip Trainer, click here for more information on both.

Xbox Kinect Workouts

ZumbaWow, I never thought I would include a video game in this type of article, sounds counterproductive doesn’t it?  The Wii was close, but the Xbox 360 with the Kinect motion sensor really does open up the possibility to offer home workout “virtual coaching” better than a pure DVD video.  The Xbox Kinect system can see you and assess the quality of your movement as you go along with the workout programs.  Games include several dance based titles that can serve as a cardio workout, but also many workout programs including:

I wouldn’t underestimate these options for home workout programs as they can be fun and motivation is the key.

Click here for more information on the Xbox Kinect Motion Sensor.

Self Myofascial Release

I really think that we are going to start seeing more of the trend towards “feeling better” in our home workout programs.  As we mentioned above, P90X2 has a new section of the program designed for recovery and mobility, and Mark Verstegan’s Core Performance programs have always featured this concept.

One simple way to start feeling better in addition to getting in shape for 2012 is self myofascial release and trigger point releases.

UPDATE:  This article has been revised and updated with newer products!  Click here to see my current list of best self myofascial release tools.

Foam Rollers

Thoracic Spine Mobility ExercisesI have reviewed many of the best foam rollers on the market right now.  I still like all my original recommendations, though one new product is also worth checking out.  I have actually gravitated to using the Grid roller myself, and I think it is great, but for those on a tight budget it is hard to justify the extra cost from the simple foam roller.

In addition to self myofascial release, foam rollers are also excellent at working on thoracic mobility, which we all really need in our society.  I showed a video of how I perform simple thoracic mobility exercises on a foam roller than anyone can perform.  Start enhancing your posture now!

Click here to check out the best foam rollers.

Trigger Point Massage Balls

Trigger Point Massage BallThe same company as the Grid roller, Trigger Point Performance Therapy, has released a trigger point massage ball that I really like.  Softer than a lacrosse ball and firmer than a tennis or racquetball with a little nub to really get into a trigger point.  This has been my go to tool for self trigger point releases over the last year or so.  I showed a technique I use for the self trigger point release of the shoulder and rotator cuff.  This is a great compliment to any foam roller you have.

Click here for more information on the Trigger Point Massage Balls.

I hope this information helps.  I am always looking for good products so feel free to comment and share your experiences too!  Good luck with your New Year Resolution to get in shape in 2012!