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As outdoor athletes, we abuse our shoulders, whether we’re climbing, pole planting, paddling, or doing anything that involves the risk of falling hard. The shoulder is the most mobile and least stable joint in the body, which means it’s highly prone to injury.
“Shoulder injuries are one of the most common injuries that we see in our clinic,” says Esther Smith, a physical therapist, climber, and owner of Grassroots Physical Therapy in Salt Lake City. Most of these cases are caused by misuse and overuse versus trauma, she says, which suggests they’re largely preventable. Injuries often begin as a dull ache or discomfort that may come and go but never seems to disappear completely. When you try to push through —as most stubborn outdoor athletes tend to do—it can develop into a sharp, debilitating pain that can be frustratingly difficult to shake.
“People will oftentimes see a medical practitioner too late, and then those injuries become hard to treat,” says Jared Vagy, a physical therapist, board-certified orthopedic clinical specialist, and the author of Climb Injury-Free. The best course of action is to address the nagging ache early on, before it becomes a full-blown injury. Below, Smith and Vagy explain the mechanism behind the three most common shoulder injuries and how to get on the road to recovery.
The shoulder forms a ball-and-socket joint, like the hip, between the head of the humerus (upper-arm bone) and the scapula (shoulder blade). In comparison, the hip joint is much deeper and relatively stable, while Vagy says the shoulder joint is like “a golf ball on a tee.” The head of the humerus is about three to four times the size of the shallow socket it butts up against, which allows for a huge range of motion at the expense of stability. The joint relies on a web of muscles, tendons, and ligaments to hold everything in place and deliver movement.
An acute injury (a sudden fall while skiing or biking, for example) or repeated stress over time, especially from suboptimal shoulder positions such as overhead reaching while climbing, can aggravate or tear any of these structures, cause them to become inflamed, and lead to shoulder pain, discomfort, weakness, and instability.
Shoulder pain presents in different ways, depending on which structures are aggravated or damaged. According to Vagy, the three most common types of shoulder injuries for outdoor athletes are shoulder impingement (a shoulder-structure-related injury), a rotator-cuff strain or tear (a muscular injury), and a labral tear (a cartilage injury). Because the structures of the shoulder are so intertwined, these injuries can be difficult to tell apart, even for trained medical professionals. Clinicians typically conduct a cluster of tests to confirm one of these diagnoses.
The following general guidelines will help you determine which category you might fall under, but keep in mind that you’ll need to visit a professional to get a proper diagnosis. If you have any doubts, it’s worth making a visit to your doctor or PT.
What it is: The supraspinatus muscle and tendon, which form part of the rotator cuff (a group of muscles that move and stabilize the shoulder), slide through a narrow channel in the shoulder called the subacromial space. When shoulders are overworked and aggravated, this space can shrink and eventually pinch the tendon.
Symptoms include discomfort (anything from a dull ache to a sharp pain) in the front or side of the shoulder. Pain typically increases when you lie on your side, raise your arm, or reach across your body or behind your back.
One common test for this injury is called the painful arc: draw a 180-degree arc with your fingertips by lifting your arm straight out to the side, starting with your arm resting at your side and lifting until your arm is pointed directly upwards next to your ear. If you feel no pain at first, but then do experience pain as your arm moves between 60 and 120 degrees (when the subacromial space is the smallest), and then no pain again toward the top of the arc, you could have this injury.
Why you get it: Overuse by repetitively moving the shoulder into the end ranges of its mobility or stressful positions is a common mechanism of injury. These types of movement patterns include overhead reaching, chicken-winging while climbing (sticking your elbows out and up—a common mistake among beginners), or holding your bike handlebars with bent, raised elbows (common among mountain bikers).
Poor posture is also a factor. When we slouch, the chest caves in, causing the pectoralis muscles to tighten. The thoracic spine flexes forward, stretching the upper-back muscles, and the shoulders round forward, which decreases the subacromial space. While this won’t necessarily cause the injury, it can make it worse and prolong the recovery process.
What it is: The rotator cuff is made up of four muscles, which connect the upper arm bone to the shoulder blade, control shoulder motion, and provide dynamic stability. These can be strained or torn, like any muscle, across a spectrum of severity, from a mild stretch to a partial tear to a complete rupture.
With this injury, pain is typically located in the side of the shoulder and can radiate toward the back of the shoulder, whereas with subacromial pain syndrome, the pain usually feels closer to the front. Pain often increases when you lift objects out to the side. To test yourself at home, stand with your back to a wall, with your arm at your side and that elbow bent to 90 degrees. Gently press the back of your forearm into the wall, which will engage a rotator-cuff muscle to externally rotate the arm. If this motion generates more discomfort or feels significantly weaker on your bad side compared to your other arm, it’s a sign you could have this injury.
Why you get it: Overuse is often the culprit for rotator-cuff injuries. Poor technique due to inexperience or fatigue in shoulder-heavy activities like climbing or weight training can increase the wear and tear of these muscles over time.
What it is: The shoulder socket is bordered by a ring of cartilage called the labrum. This tough yet supple tissue cushions the joint, cups the head of the upper arm bone to help hold it in place, and allows everything to move smoothly. When the arm is jammed into the end ranges of its mobility, it can stress or tear this cartilage. Labral tears can vary in size and location and fall into specific categories—a common type for outdoor athletes is called a SLAP tear (superior labrum anterior and posterior), which occurs at or near the top of the socket.
This injury is typically more severe and debilitating than the first two. Symptoms include a deep pain in the shoulder, which increases with lifting or overhead reaching; a catching, clicking, or popping feeling; stiffness, instability, and weakness; and reduced range of motion.
Why you get it: A hard jolt or sudden force to the shoulder (a fall onto an outstretched arm, for example) is the most common cause, but around 30 percent of labral tears develop gradually from overuse and repetitively hammering the joint into the extreme ends of its range, according to a study published in the journal Arthroscopy.
“My advice is always to keep doing what you love, but do it with modification, and be smart about it,” says Vagy. At the first sign of shoulder pain, dial back what you’re doing, avoid any moves that hurt, and correct your movement patterns. Smith seconds that—many of her patients are able to keep up their sports while they recover, though others do benefit from a period of rest to calm inflammation and irritation.
After two weeks of modified activity or rest—and only if the pain has lessened—Vagy suggests trying the exercises below. Only perform them if you can do each pain-free. If you have any doubts whatsoever, see a medical professional for a proper diagnosis and rehabilitation plan.
The moves are broken down into three categories: unloading, mobility, and strength. The unloading and mobility exercises are a catchall, Vagy says; they’ll work for all three of the shoulder injuries mentioned. These should be done every day, up to three times per day. The strength exercises will benefit all three injuries as well, but you can adjust the strength work based on the injury you think you might have. If you think you have a rotator-cuff strain, for example, do an extra set of the shoulder-rotation exercise. Perform the strength exercises every other day.
“While self-treating, if you experience increased pain during or after exercises or have new pain or symptoms, we recommend that you seek medical advice,” Smith says. “Adjust the frequency, intensity, load, resistance, or position to manage any discomfort. Listen to your body, and stay within a therapeutic range of movement.”
Work on your posture and shoulder mechanics, too. Movement reeducation is the final and most important aspect of the recovery process if you want to avoid re-aggravating the injury.
What it does: Slouching places more pressure on the rotator cuff and labrum. Good posture keeps your spine and shoulders in a neutral position, which opens up this space and reduces the strain on these structures.
How to do it: Stand or sit up straight. Lift your chest, pull your shoulders back and down, keep your neck in a neutral position, and hold your elbows close to your body.
Maintaining this position all day is easier said than done once you’ve fallen into bad habits. There are numerous posture-correction tools on the market designed to help, from braces and straps to high-tech wearables such as the Upright Go 2, but what matters most is that you work at it consistently—and be mindful of every component—until good posture becomes second nature. One easy and free technique Vagy suggests is to set a reoccurring alarm for every 30 minutes. When it goes off, bring your attention to your posture and reset as necessary. At first you might slump back toward your screen within a few minutes, but over time, you’ll be able to maintain good posture for longer and longer durations until it becomes the new norm.
How to do it: Lie on your back on a foam roller, with your spine perpendicular to it and the roller situated at the base of your shoulder blades. Interlock your fingers behind your head to support your neck, and lower your elbows out to the sides to open your chest. Keep your knees bent, feet flat on the floor, and core engaged. Press though your feet to raise your hips off the floor. Then gently roll back and forth, focusing on your upper back.
What it does: Stretches the pectoralis muscles to help open the chest and allow the shoulders to shift back into a neutral position. “Outdoor athletes tend to have rather flexible chests when their arms are at shoulder level, but where we lack mobility is when we lift our arms overhead to about 135 degrees,” says Vagy. Mobility in this position is especially important for overhead-reaching sports, such as climbing.
How to do it: Before you stretch, use a massage or lacrosse ball to roll out and loosen the chest muscles. Hold the ball against a wall or doorframe at chest level, gently lean your body into it for pressure, then move your torso to roll the ball around each pec for a minute or two (only target the muscle and avoid rolling over the sternum or clavicle bones).
For the stretch, stand in an open doorframe and place your forearms vertically on each side, with your elbows at shoulder level and bent to 90 degrees (this arm position targets the clavicular fibers of the pectoralis-major muscle). Gently lean or step forward to engage a chest stretch. Hold for 30 seconds. Next raise your arms overhead so that your upper arms are roughly 135 degrees from your torso (this targets the sternal fibers of the pectoralis major). Once again, gently lean or step forward to engage a stretch, and hold for 30 seconds.
What it does: Improves shoulder mobility and strengthens the upper back to help retract the shoulder blades, extend the thoracic spine, and return the shoulders to a neutral position. This is the primary strength exercise for shoulder impingement/subacromial pain syndrome.
How to do it: Stand with your back against a wall or door, your feet six inches away from the base, with a slight bend in your knees. Engage your core to flatten your back against the wall, including your low back. Look straight ahead to keep your neck in a neutral position. Then raise your elbows up to shoulder level (bent to 90 degrees). Squeeze your shoulder blades together to press your elbows and the back of your hands against the wall, if you can. This is the starting position. From here, slowly slide your arms up the wall as far as you can without losing form (keep your forearms vertical throughout the movement, and avoid arching your lower back), pause for a second, then return to the starting position. Continue sliding your arms up and down for 30 seconds. If your sport involves overhead motion, try the exercise with straight arms as well, since this better mimics the movement pattern.
If you lack the mobility to stand against a wall in a neutral posture or hold your arms against the wall without arching your lower back, try performing the exercise as described above but while lying flat on your back on the floor to use gravity for assistance.
What it does: Strengthens the rotator-cuff muscles to improve shoulder function. This is the primary strength exercise for rotator-cuff strains.
Internal rotation with a low elbow—Tie one end of a resistance band to an anchor point at waist height, like a pole or doorknob. Grab the other end of the band, stand with the shoulder of that arm facing the anchor point, and step away to give tension to the band. Hold your arm by your side, with your elbow bent to 90 degrees and your hand aiming forward. Then engage your shoulder blade and rotate your arm toward your abdomen. Slowly reverse the movement for one repetition. Complete all reps, then switch to external rotation.
External rotation with a low elbow—From the aforementioned position, rotate your body 180 degrees or switch arms, so the band now comes across your abdomen. Rotate your arm out to the side against the band (making sure to keep your elbow bent to 90 degrees), then slowly let it return to the starting position. Repeat.
If your sport involves overhead reaching, progress the exercise by performing it with your elbow at shoulder height, which better mimics the movement pattern.
Internal rotation with a high elbow—Tie one end of a resistance band to a fixed object at shoulder height. Grab the other end, and stand with your back to the anchor point. Raise your elbow to shoulder level, and hold it out to the side, bent to 90 degrees. Then rotate your arm to pull the band forward until your forearm is parallel to the floor (keeping your elbow bent to 90 degrees). Slowly reverse the movement until your forearm is vertical, and repeat. Complete all reps, then switch to external rotation.
External rotation with a high elbow—Keep your arm in the air, and turn around to face the anchor point. Slowly rotate your arm to lower your forearm until it’s parallel to the floor, then pull against the band to return to the starting position (keeping your elbow bent to 90 degrees throughout the movement). Repeat.
What it does: Challenges the stability of the shoulder and strengthens the muscle on the side of the chest that stabilizes the shoulder blade. This is the primary strength exercise for labral tears.
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How to do it: Start in a high-plank position (like you’re doing push-ups), with your hands on the floor shoulder-width apart, your arms fully extended, and your feet together or no more than 12 inches apart. Engage your core, and keep your spine neutral so that your body forms a straight line from your head to your feet. Then push up through your arms to lift your shoulder blades and bring your shoulders forward (it’s a subtle movement). From here, transition into a side plank by rotating your hips to one side until they are perpendicular to the ground, with your feet either stacked or both on the ground (easier for balance), and raise your upper arm toward the sky in line with your supporting arm on the ground. Pause for a few seconds, then slowly reverse the movement to return to a high-plank position. Repeat, this time rotating to the opposite side for the side plank.
If the high-plank position is too difficult, perform the exercise as described above from a low-plank (forearm-plank) position.
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