Hardly any sentence is heard more often on the training floor than “my shoulder is pinching”. Sometimes it is a trifle, sometimes there is a clinical picture behind it that belongs in medical hands. As a trainer you do not make a diagnosis and you do not treat – but you have to understand what can happen in the shoulder joint in order to ask the right questions, to refer on in good time and to adapt the training sensibly. This article sorts the most common shoulder complaints and deliberately draws the boundary of your own role clearly.
Why the shoulder reacts so sensitively
The shoulder joint is built for mobility, not for stability. The head of the humerus is not guided by a deep socket but by muscles: the rotator cuff is formed by those muscles that come from dorsal, attach to the head of the humerus and enclose it like a cuff – the supraspinatus, the infraspinatus, the teres minor and the subscapularis. Their task is to centre the head of the humerus in the glenoid cavity in every arm position.
Above them lies the shoulder roof. Between the rotator cuff and the shoulder roof there is a bursa, and that is exactly where it gets tight. The fact that the shoulder is not loaded statically in upright gait incidentally has a pleasant consequence: osteoarthritis is rarer in the shoulder joint than in the joints of the lower extremities. When it does occur, it is often secondary, following injuries to the ligaments or the rotator cuff with subsequent faulty loading.
Impingement: the most common picture
Impingement is the term for the abutment or contact phenomena of the rotator cuff and the subacromial bursa at the coracoacromial arch. In practical terms this means: during certain movements – often in 60 to 130 degrees of abduction – pain arises between the rotator cuff and the bursa. It is usually caused by the tight spatial conditions under the shoulder roof, which lead to mechanical irritation. Typical signs are restricted functionality of the shoulder joint and pain on movement.
Impingement is often treated with painkillers in combination with physiotherapy. For you the decisive sentence is a different one: training takes place only after consultation with the doctor or the physiotherapist. What then follows is frequently a targeted balancing of dysbalances between the individual muscles of the rotator cuff and the shoulder joint. How to recognise dysbalances in the first place is shown in the article How to recognise and correct muscular dysbalances.
Rotator cuff: from irritation to rupture
An injury to the rotator cuff can arise acutely and traumatically, for example after an accident, or chronically and degeneratively – through wear, for instance in overhead work. The rupture is graded according to the number of torn muscles and leads to a loss of function of the upper arm; in the worst case the arm can only be abducted by a few degrees. Overhead work is no longer possible, internal rotation is painful, night pain always occurs and those affected cannot lie on the shoulder. Diagnosis is made by MRI or ultrasound – so expressly not on the training floor.
With a complete rupture, surgery is unavoidable in the vast majority of cases, and it should take place without delay because the tendon degenerates rapidly. After the operation the shoulder joint is immobilised for four weeks; active mobilisation and strengthening with light resistance then begin, and movements with acceleration have to be avoided. Rehabilitation is delicate and depends heavily on tissue quality; re-ruptures are not uncommon. Physiotherapeutic supervision is necessary in the first few months. Only after consultation with the doctor and the physiotherapist – usually after around two months – can strengthening be continued in the fitness centre.
Excursus: the San Antonio programme
Rebuilding after a rotator cuff rupture includes carrying out what is known as the San Antonio programme. It is reproduced as an exercise chart of its own and comes from the physiotherapeutic field. What matters is how it is classified: it is a rebuilding programme within follow-up treatment, not a training programme you set up on your own initiative. It is instructed within the framework of therapy; in the training course it is discussed on the basis of the chart so that you know what your guests are talking about when they come to you with such a programme from physiotherapy, and so that your training can connect to it instead of running alongside it.
Further clinical pictures you will encounter
Shoulder dislocation
In a complete dislocation the head of the humerus slips out of the glenoid cavity, usually to the front and downwards, and overstretches the anterior capsule and the ligaments. It can arise traumatically – frequently in ball, contact and high-speed sports such as skiing or snowboarding – or habitually, when an anatomical abnormality is present, for instance a socket that is too flat. The dislocation leads to an immediate loss of function and causes severe pain. A dislocation can trap and damage nerves, which is why it must never be reduced by lay people, but only by a doctor.
Conservative treatment immobilises the arm for around four to six weeks after reduction; during this phase triggering movements such as abduction in combination with external rotation should be avoided. Taking up regular strength training depends on the extent of the trauma and as a rule happens only after two to three months. Caution is then required with flyes, wide bench press and lat pulldown; bent-over rowing, close-grip bench press, arm curls, arm extensions and shoulder shrugs are regarded as safe exercises. In general, caution applies to large ranges of movement with the arm raised.
Tendinitis calcarea – the calcific shoulder
Here calcium is deposited in the tendon attachments of the rotator cuff, which leads to repeated, very painful inflammations of the entire shoulder region. Typical is the painful arc: abduction in particular triggers severe pain in the middle of the range of movement. It is partly triggered or activated by a change in the weather or by unaccustomed or increased loads – gardening, house moves or learning new sports such as golf or tennis. It mostly occurs after the age of 40; the cause is not known.
In an acute phase the training has to be modified, and aggravating activities are taken out of the programme. In strength training, attention has to be paid to the position of the shoulder blade and the shoulder girdle so that the shoulder does not move into protraction during the exercises and the shoulder blade does not lift off the thoracic wall. Sometimes athletes benefit from slightly altering the movement pattern – for instance using free weights instead of a machine, or modifying the exercise.
Subacromial bursitis
Inflammation of the bursa usually arises secondarily through repeated traumatisation, for example in the context of an impingement. The symptoms are pain in the shoulder as well as restricted movement and weakness. In the acute situation it is essential to move the shoulder in a measured way in order to prevent it from stiffening, to avoid overloading – and not to train during this phase. As soon as the acute situation is over, strengthening of the entire shoulder girdle musculature can begin step by step; strong and functionally trained musculature prevents the impingement and with it the inflammations. Caution is required with overhead movements, and no symptoms should occur in the arm during the exercise.
Frozen shoulder
What is meant are chronic, inflammatory changes in the area of the shoulder joint capsule that lead to temporary stiffening. The course runs in three phases: first severe pain, which severely restricts movement and lets the shoulder “freeze”; then the pain subsides, but mobility hardly improves; finally mobility slowly gets better again. In bad cases the entire cycle lasts nine months. From the beginning of the third phase, strengthening of the entire shoulder musculature as well as an extensive muscle-lengthening programme make sense in training – it is then of great importance that the shoulder is again used in a functionally normal way.
What this means for your training
The same points run through all of these pictures. First: with an acute inflammation you do not train, you modify or pause. Second: overhead movements and large ranges of movement with the arm raised are the candidates you look at first. Third: the position of the shoulder blade and the shoulder girdle decides more than the weight – no protraction, no shoulder blade lifting off. Fourth: pain is not a training stimulus; no symptoms should occur during an exercise. And fifth: a cleanly executed movement pattern can be adapted without losing the training stimulus. For long-term development it pays to think about posture and mobility as well – the articles Effective posture training for your back and How your mobility training can prevent injuries fit in here.
Where your role ends
The update Akademie trains trainers, not therapists. That is not a formality but a professional boundary: distinguishing between subacromial bursitis and supraspinatus tendinitis is difficult even medically, because the symptoms are very similar – in stubborn cases ultrasound or MRI is needed. Nobody on the training floor can replace that, and nobody should try. Your task is to take complaints seriously, to adapt the training, to work towards a medical or physiotherapeutic assessment and afterwards to work within the clearance that comes from there. A guest who comes to you with night pain, a sudden loss of strength or a movement block belongs in an assessment – not in an additional exercise.
Training tip from the update Akademie: anyone who regularly works with guests who bring complaints with them needs this knowledge in a structured form, not as a collection of individual cases. The course Gesundheitstrainer/in with SVBO industry certificate goes deeper into exactly this interface between training and health, including the clinical pictures of the musculoskeletal system and the question of when you refer on. Anyone who only wants to deepen the pathophysiological part will find it in the workshop Die Pathophysiologie – an in-depth look at health limitations.
Frequently asked questions about shoulder pain in training
What is an impingement in the shoulder?
Impingement is the term for abutment or contact phenomena of the rotator cuff and the bursa under the shoulder roof. Pain often occurs at around 60 to 130 degrees of abduction, caused by the tight spatial conditions and the resulting mechanical irritation. Typical are pain on movement and restricted function of the joint.
May I carry on training with shoulder pain?
That is not decided by the training but by the assessment. With acute inflammation you pause or modify the programme, and training is resumed only after consultation with a doctor or physiotherapy. The basic rule is: no symptoms or pain should occur in the arm during an exercise.
Which exercises are delicate with shoulder problems?
Delicate above all are overhead movements and large ranges of movement with the arm raised. After a shoulder dislocation, flyes, wide bench press and lat pulldown are exercises requiring caution. Bent-over rowing, close-grip bench press, arm curls, arm extensions and shoulder shrugs are regarded as safer.
What is the San Antonio programme?
It is an exercise programme from the physiotherapeutic field that is part of rebuilding after a rotator cuff rupture. In the training course it is reproduced as an exercise chart and discussed in class. It is instructed in follow-up treatment by the therapy, not independently on the training floor.
How long does a frozen shoulder last?
The shoulder passes through three phases: severe pain with stiffening, then subsiding pain with hardly any improvement in mobility, and finally the slow thawing. In bad cases the entire cycle can last nine months. The prognosis is favourable in the end; as a rule the shoulder recovers quite well.
Conclusion
Shoulder pain is not a single problem but a family of clinical pictures with very different consequences for training. What they have in common is that the assessment comes before the programme, and that the position of the shoulder blade, overhead movements and freedom from pain during the exercise are the most important adjusting screws. The better you know the pictures, the more precisely you can observe and refer on – and the less you will be tempted to treat them yourself. That is exactly where the boundary runs: you shape the training, while diagnosis and treatment belong in medical and physiotherapeutic hands.
