by Dr. Matt Fontaine
Debunking Shoulder Pain in the CrossFit Athlete– Part I
In this 3 part series I will address the causes of shoulder pain in the overhead athlete. Keep in mind that shoulder pain is not unique to CrossFit, but comprises about half of all CrossFit related injuries.
I will do my best to show how much of the information that is out there, while in part helpful and correct, is often not comprehensive and misleading. Many of the quick fix “Do this Exercise” posts to fix your shoulder pain leave much expertise to be had, leaving the reader/athlete with an incomplete explanation of the big picture and the true causative factors which are all too often multifactorial in nature.
I. Defining the Problem: It all starts with an accurate diagnosis.
With any musculoskeletal pain syndrome lasting longer than 2 weeks, getting an accurate diagnoses by a well-trained sports medicine physician is paramount. The spectrum of most shoulder injuries covers basic functional shoulder impingement, biceps and rotator cuff tendonitis to the more severe partial and full thickness rotator cuff tears and labral tears.
Let us take a deeper dive
Assessing biomechanics properly
The best starting point is a review of the problem. Where does it hurt and with what movements? What were the mechanisms of injury? Was there trauma or just a gradual onset due to repetitive motion injury. A good history of the chief complaint can answer many of these questions. The 3 most common key issues at play are typically:
1. Muscle imbalance
2. Rotator cuff adhesions from Repetitive Motion Injury which result in early fatigue of these muscles which leads to impingement and pain.
3. Poor Positioning of the shoulder girdle
The shoulder is a complex region of the body. It is a highly mobile region susceptible to injury. Full unimpeded range of motion of the shoulder requires complex coupled motion at the ball and socket joint (glenohumeral joint). Full functional use of the shoulder requires optimal mechanics of 5 joint regions, namely:
The Big 5:
The Ball and Socket and Scapulothoracic Joint
Comprised of the glenohumeral joint and scapulothoracic joint. Admittedly, I will geek out a bit here on biomechanics. If you’re not into it, just note that full unimpeded movement at the shoulder depends on a well synchronized movement of the ball and socket and shoulder blade together. These joint regions allow for 180 degrees of shoulder flexion, 180 degrees of abduction, 45 degrees of extension, 90 degrees of external rotation and 50-70 degrees of internal rotation. The GH joint and scapulothoracic joint move in synchrony in a healthy shoulder. There is a 2:1 ratio of glenohumeral movement to scapulothoracic movement. Some key movements here:
A. From 0 degrees abduction (arm at side) to 90 degrees Abduction, the GH joint moves 60 degrees and the scapula must rotate outward 30 degrees.
B. From 90 degrees Abduction to 180 degrees Abduction (arm fully in the overhead position) the GH joint moves another 60 degrees and the scapula rotates another 30 degrees while the clavicle rotates posteriorly
The Acromioclavicular joint and the Sternoclavicular joint
The AC joint is where the clavicle joins the scapula and the SC joint is where the clavicle joins the sternum
The Cervical and Thoracic Spine
The joints of the lower cervical spine must be mobile to accommodate movement of the first rib and clavicle. The thoracic spine must have good mobility in extension to allow for full overhead range of motion.
Roll and Slide of the Ball and Socket
The Key to the Roll & Slide: the subscapularis is the primary stabilizer of the shoulder GH, compresses the humerus and pulls it inferior to allow roll and slide during ABD.
fig. A depicts arm at the side, ball in socket.
fig. B depicts shoulder in overhead position
fig. C depicts full overhead position, ball rotates downward to avoid impingement.
fig. D. depicts the shoulder joint and capsule
The serratus anterior keeps the scapula sucked to the rib cage, but when adhered to the subscapularis due to RMI, the serratus becomes fatigued and inhibited, as does the subscapularis. There are several ways to work on improving stability of the shoulder girdle, including CrossOver Symmetry System. However, when the muscles are glued down, the most important thing is to address these adhesions first while simultaneously starting a stability program.
Mobility/Stability Motor Control of the Shoulder Complex
Stability is often posited as the key to resolving shoulder pain, and while it is very important, it is not the end all be all. Focusing only on stability is a narrow aperture that causes several vital factors to be missed
- Scar tissue and the hypoxic fibrous adhesion pathway. Simply put, overworked soft tissues due to RMI become tight, resulting in hypoxia, which leads to the myofibroblast cell to lay down fibrous scar tissue. Scar tissue in the capsule with prevent roll and slide.
2. The rotator cuff only stabilizes and positions the humerus on the glenoid> golf ball on tee (picture).
3. Latissimus and trapezius/ serratus: in a healthy, normally functioning shoulder these muscles are freely moveable and slide to produce a much larger, global stabilizing effect on the shoulder girdle.
A Note on Mobility
Many athletes today use foam rollers, lacrosse balls and super bands to mobilize stiffness in the soft tissues. If consistent attempts to release the latissimus and posterior rotator cuff with foam roller / lacrosse ball are ineffective, this may be a telltale sign of more serious pathology in the GH joint, namely instability due to a rotator cuff tear or a labral tear. This recurring tightness is guarding tension and is protective in nature. Meaning, the instability must be addressed in order for these tissues to be successfully released.
Proper Positioning vs. Poor Positioning of the shoulder
In future parts in this series we will dive deeper into shoulder impingement, tendonitis, rotator cuff tear and labral tear. We will also look at some of the commonly prescribed rehab exercises for the shoulder, discuss their shortcomings and learn better, more effective exercises to address resolving shoulder pain. Specifically we will discuss
1. Learning how to pack the shoulder
2. The short comings of the Y,T, and I stability exercises
Learn more about Active Release Techniques, a fast and effective treatment for soft tissue injuries.