Chronic shoulder injuries are quite common in age-group and amateur athletes. This article chronicles my personal shoulder rehabilitation journey.
This is a long post, so you might want to grab a coffee before you start.
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I don’t want to spend a long time telling you about my sporting background and how it led me to needing to spend quite significant time on shoulder rehabilitation. However, a little basic information might help, so bear with me for this first bit.
I started triathlon in the late 1980’s as an almost non-swimmer (I knew how not to drown) and taught myself to swim before getting a coach. The result: I had a lot of bad habits, especially in my arm recovery, the place where shoulder damage occurs.
Swimming up to 8 sessions a week until 2007, admittedly with some extended breaks, I fixed a lot of the stroke flaws but suffered pain from what I assumed was permanent wear and tear on my shoulders. In 2007, I finally gave up swimming because my shoulders were just to painful to keep doing it.
My shoulders didn’t get any better. Yes, they’d be fairly pain-free. Then I did something that taxed them, and I’d be back in pain again.
In 2013, I discovered Pavel Tsatsouline, the RKC and Strongfirst. I saw kettlebell swings as a great way to strengthen my posterior chain to overcome the bad things that being a cyclist were doing to my body and my posture.
Then, in 2014, I had the chance to attend the Strongfirst SFG1 certification and had to learn the various exercises that would be tested on the course. Amongst those was the Turkish Get Up.
In learning the Get Up and practising it obsessively, I found that my shoulders started to feel significantly better. This was especially noticeable because the military presses and pull-ups initially caused me to suffer significant pain and time off training those two exercises.
I passed my SFG1 and went on a quest to fix my shoulders permanently - or as permanently as possible. It’s taken me years to get to where I am now. If you’re active and adventurous, this is going to be the case. There are no quick fixes.
I’ve mentioned my shoulder rehabilitation often on Twitter and have had a lot of people ask me how I did it.
As you’ll find out if you read this whole post, it’s far too much and far too complex to tweet. What’s more, shoulder rehabilitation is not a "paint by numbers", “do this then do this” post because we’re all different.
I hope you’ll find some tips in here that will help you or someone you know to banish their shoulder pain.
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Why is the Shoulder Joint Vulnerable?
This is a very simplified description of what happens at the shoulder joint that makes it vulnerable. It’s not meant to be a strictly scientific description of the shoulder joint anatomy and shouldn't be used that way. Instead, it's my simple coach to athlete explanation.
The Sacrifice of Stability for Mobility
The hip and shoulder are both ball and socket joints, but they differ in terms of mobility and stability.
The hip is a very stable joint due to the sheer amount of muscle and connective tissue surrounding the joint. It also has a more significant socket as part of the bony joint itself.
In order to allow you to have far more mobility in the shoulder, it has a shallower socket and a lot less supporting tissue. The shoulder is held in the socket by a group of small muscles called the rotator cuff. If the ball of the shoulder joint is not properly centred in the socket, these small muscles can become trapped/squeezed in the joint, with the result that they become inflamed: the rotator cuff issues that many people suffer with.
Lifestyle has negative effects on posture
Normal posture has the shoulders in a neutral position, with the muscles that work to retract and depress the shoulder girdle (pull it back and down) balancing out the effects of those that protract and elevate it (pull it forward and up).
Our modern lifestyle means that most people live their lives in a protracted (forward-rounded) position which results in something called adaptive shortening in the muscles that pull the shoulder girdle into that position.
Think about the positions in which we spend most of our lives…
- Sitting and working at a desk
- Watching TV
All of these activities contribute to that protracted, internally rotated position.
What’s more, the chest musculature that protracts the shoulder girdle also puts tension on the shoulder joint and pulls the ball out of its ideal alignment in the shoulder socket.
Poor Thoracic Spine Mobility
Your ability to get your hands overhead relies on you having a good level of thoracic spine mobility. The easy way to think of your thoracic spine is those vertebrae that have ribs attached.
Again, this mobility is something that is negatively affected by our modern lifestyles. My physiotherapist tells me that most people she sees - whether athletes or not - have atrocious mobility in their thoracic spine.
This lack of mobility in the thoracic spine means that your body will look for mobility elsewhere in order to get your arms overhead. Your body has an amazing ability to find ways to do whatever you want it to do, whether those workarounds are ideal or not.
The two main places where you’ll try to find find mobility are…
- Lumbar spine (lower back)
- Shoulder joint
Over an extended period, the result of this search for mobility is often pain. Finding movement in the lumbar spine can result in lower back pain, whilst looking for it in the shoulder can, all too commonly, result in shoulder pain.
A lot of people make the mistake of thinking that their lack of ability to get their hands overhead is due to a lack of shoulder flexibility. Their efforts at shoulder rehabilitation by creating more range at the shoulder itself results in strain on the both shoulder capsule and rotator cuff. I did this to myself a lot!
My Shoulder Rehabilitation
I must stress that what follows isn't medical advice, it's the story of what I did for my own shoulder rehabilitation.
That means one of two things...
- What I did might not work for you.
- What I did might actually work for you.
The most important advice I can give you is to try things and take note of what works to make a positive change. Keep what works for you and abandon what doesn't.
I'm not naive enough to think that anyone is going to do the same exercises daily once they've resolved their pain. With that in mind, what I suggest is that you make a note somewhere safe of the approaches that work for you, so that you're able to return to them if your pain shows up again. In a world of novelty, most people don't do this and they usually live to regret it.
With that said, here are the approaches I used...
Using the RAIL System to get Shoulder Rehabilitation Started
The first thing I did to get out of pain was to use the RAIL system from Dr Perry Nickelston of Stop Chasing Pain. I wrote about this in my article about calf injury healing.
In summary, Dr Perry’s system works by recognising that the body is a unit in which it’s possible for some muscles to become “lazy” and for others to take over their workload. These muscles then become tight and sore when they’re overworked.
The RAIL acronym stands for Release, Activate, Integrate, Locomotion and this is what I did.
My first step was to release the tight muscle. I did this by lying with a lacrosse ball along the margins of my shoulder blade. I’d move until I found a sore spot and apply increasing pressure until the soreness disappeared.
Funnily enough, during my swimming days, I’d found that doing this with tennis ball had provided temporary relief from the same pain. I just didn't know how to make the change stick.
The activation part of the process aims to get the muscles that should move the shoulder to fire properly.
I did this by placing my hand in my armpit and squeezing my hand as hard as I could between my arm and my body. The focus must be on using the lats and pecs to squeeze the arm into the body.
I did this 4 or 5 times for a count of five each time.
[You may have to repeat the Release and Activate steps a few times.]
This step aims to get the muscles around the shoulder working properly in concert with each other and your core musculature.
I took up a 4-point box stance on all fours. Then, I rocked back onto my heels and then forward until my shoulders were forward of my hands. It’s important to do this by pushing and pulling with the arms, not by moving from the hips. All the time, I was focused on keeping my shoulders down and back.
Ten cycles of this movement worked for me.
The last step is to integrate the movement into something that looks like walking (at least a bit).
The exercise is a lunge, but with the addition of bringing the arms up at the same time so that your upper arms are parallel to the ground while trying to touch your elbows together.
Again, ten cycles should do.
Finally, I went for a short walk, making sure to swing my arms naturally.
The Exercises I Used for Ongoing Shoulder Rehabilitation
While the RAIL system worked well for getting out of pain, I’ve used a number of other exercises to work on my shoulder rehabilitation on an ongoing basis.
Each one addresses things from a different angle and I have used them all at one time or another. Many of them make a regular appearance in my programming and some appear only occasionally.
Why so many? Well, my grandfather was a carpenter and he taught me that you should always use the right tool for the job. The more tools you have, the more potential you have of getting a better result.
Over time, I've got to know what sort of shoulder discomfort responds to each exercise. It's an experience thing and is virtually impossible to describe in writing.
Experiment with them all, observe the results you get with each and keep the ones that work for you.
Turkish Get Up
It’s no secret that I love the Turkish Get Up for a whole bunch of reasons.
Among those reasons is that it’s great for re-educating your shoulder proprioceptors in several different positions. The offset nature of the load provided by the kettlebell provides a challenge which encourages proper activation of the lats to pack the shoulder.
The main thing I learned in my study of the Turkish Get Up was Brett Jones’ saying: “Ears are shoulder poison.” Keep your shoulders packed down and away from your ears.
The Turkish Get Up was where my shoulder rehabilitation journey started. Once I’d had some success from that exercise, I started looking for other ways to enhance my progress.
Thoracic Spine Extension - Lacrosse Ball “Peanut” and Foam Roller
Early on, when I was working on the kettlebell military press, I realised that I was only able to get the kettlebell properly locked out by arching my lower back or forcing the shoulder joint beyond its comfortable range.
My reading and discussions with several physios pointed to a lack of thoracic extension. Apparently, this is common in our desk-bound, car-bound world.
Addressing this was simple, although uncomfortable at first.
This mobility exercise is as simple as taping two lacrosse balls (or tennis balls) together, placing them, one each side of your spine anywhere in your thoracic region and lying on them until you are able to relax into extension.
I used to repeat this on two or three sections only. It’s very easy to do too much and feel really beaten up the next day.
Once you have a little more mobility, you can do the same with a foam roller.
Adding arms overhead will add leverage and increase the range you can get.
This is another exercise that made big changes in my shoulder rehabilitation.
T-Spine Rotation - Book Openers and Bretzels
Another aspect of thoracic spine mobility is rotation.
I used two main exercises for this...
Lying on one side with your arms out at 90° to your body, pull your legs up so that they are 90° at the hip and knee.
Rotate from the mid-back drawing your top shoulder towards the floor. Keep the top arm straight move it with the shoulder. The back of the top hand should end up on the floor. Relax into the stretch and breathe for at least 5 breath cycles.
Named for Brett Jones, who first demonstrated this exercise, this is a slightly more active mobilisation for your thoracic spine.
Lying on your side, similar to the book openers, grasp the bottom foot behind you and the top knee in front of you. Aim to get your shoulders flat on the floor (don't force it, relax into it).
Resist straightening your legs with your hands as you breathe in and relax as you breathe out. Repeat for 5 breath cycles.
Traction - Hanging or Bands
Your shoulder pain can be caused by irritation of the rotator cuff musculature because they get inflamed due to being compressed within the joint. In fact, most shoulder pain is caused this way. It helps a lot to apply a bit of traction to the joint.
These are two easy ways to do just that.
Passive hanging from a bar or rings (or anything really) uses your bodyweight to apply traction to your shoulders. You simply hang from the bar and relax.
The main limitation on hanging is your grip endurance. Obviously, you can only hang for as long as you can hold on.
One minute is most people’s absolute limit and you might question the value of the trade-off of sore hands that result, at least initially.
An alternative to hanging is using a band to apply traction to the joint. Simply attach it to a high attachment point and apply traction overhead in a similar position to that you'd get if hanging.
A useful addition to this is to take the arm into external rotation as you apply traction to the joint.
Two minutes is a good amount of time to hold this position in order to make a change.
Pec Release and Bands to Teach Position
As we saw above, the pecs can be overactive, causing forward rotation of the shoulders.
To address this, the first step is to release the tightness in Pec Minor. You do this by finding the tight (sore) spot in the muscle with your fingers and stretching the muscle while you pin the tight spot in place.
You can do this even better by using a lacrosse ball instead of your fingers, rotating it to take up the slack in the tissues before stretching the muscle.
Then you re-educate the internal rotation position of the shoulder by hooking a band around the elbow with the back of your hand on your sacrum and walking forward to apply a distraction force backwards. Contracting against the band and then relaxing should allow you to get a bit more range.
Internal and External Rotation - Rotated Floor Angels
This is my “go-to” whenever my shoulders start to get “tweaky”.
It’s hard to explain, so just watch the video.
Kettlebell Arm Bar
The kettlebell arm bar is another of those exercises that addresses thoracic spine mobility.
The kettlebell is only there to provide feedback. Lighter is better, it’s a mobility drill, not a strength exercise. Again, the video explains it best.
Elastic Band Exercises
The humble elastic band is easy to set up, can be taken everywhere and provides a lot of options for mobility work.
I do these every day, 20-30 reps. Zach Homol reckons he does 100 a day.
The point is, in a world that encourages forward flexion and internal rotation, this is an exercise that will make a world of difference to the health of your shoulders because it encourages the exact opposite. Try to keep your elbows down, focus on pulling with your hands with your thumbs facing backwards.
Band Pull Aparts
Partner these with face pulls for best effect. To encourage external rotation of the shoulder - it's natural position as you raise your hands - do these palms up and at or slightly above head-level.
I started doing these as part of my warm-up before swimming. It’s a great way to switch on the back musculature to balance what’s happening at the shoulder.
In the swimming warm-up, they were without resistance, but experimentation has shown that they’re probably better with a band.
Simply adopt each of the positions and hold for 5 breath cycles.
Focus on pulling your shoulder blades together and down throughout. A good cue is to think about putting your shoulder blades in your pockets.
Banded Overhead Press Warm-Up
This one is an exercise for warming the shoulders up before any press workout.
Simply attach the band to something in front of you, grab the band at about shoulder width and perform presses overhead as if doing a military press. The band from the front will force you to engage your rear deltoids and other muscles in your back, which means they'll fire better when you get to pressing.
Finally, an exercise I use in every warm-up because it helps to switch on the musculature around the shoulder. Use a kettlebell that is well within your ability: this is a warm-up drill, not a strength exercise.
Grasp the kettlebell with what I can only describe as an "upside-down" grip and clean it to just below your chin. From there, you simply halo it in a fast but controlled manner around your head.
If you don't have a kettlebell, you can do an unweighted version by interlacing your fingers and performing a similar movement.
As you'll have read, I have used a lot of different methods and exercises to fix my shoulders. Until I sat down to write this article, it all seemed pretty simple, but it quickly became clear that it has been a long and complex undertaking.
If you were to take just one thing from my experience, I hope that it will be that the human body is amazing at repairing itself if given just a little help and if that repair is approached with patience.
I mentioned in the introduction that I gave up swimming in 2007. Well, the story doesn't end there because I went back to swimming about 2 years ago and was not only able to swim 5 sessions a week for 6 months, but I was almost as fast as I was when I was knocking out 35,000m per week.
Best of all, I was pain free. While I don't swim that many sessions a week any more, I have not suffered any shoulder pain at all.