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Exercise Modification Strategies to Prevent and Train Around Shoulder Pain

Escalante, Guillermo DSc, ATC, CSCS, CISSN

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Strength and Conditioning Journal: June 2017 - Volume 39 - Issue 3 - p 74-86
doi: 10.1519/SSC.0000000000000259



Strength training has evolved into an activity that is widely practiced for a variety of reasons. Evidence suggests that strength training has positive effects on the musculoskeletal system as well as in the prevention of osteoporosis, sarcopenia, lower back pain, and other disabilities (50). The benefits of strength training for athletes have also been well documented (51). The Centers for Disease Control estimated from a survey given between 1998 and 2004 that nearly 20% of adults between the ages of 18–65 years old participate in some sort of resistance training 2 or more times per week (7). The increase in the participation of resistance training has naturally led to an increase in the rates of injuries related to resistance training (13,20,21,28,37,38).

Injuries to the shoulder complex account for a large proportion of injuries caused by resistance training (5,8,13,16,21,25,28,37,38,45). Calhoun and Fry (5), for example, investigated injury rates and profiles among elite powerlifters and found that 17% of their injuries were to the shoulder region. Siewe et al. (45) studied injuries and overuse syndromes in bodybuilders and reported that 36% of their subjects reported previous shoulder disorders. Kolber et al. (25) reported that even the recreational weight-training population may be predisposed to subacromial impingement syndrome because of some of their specific exercise selections and techniques.

There are several potential explanations for the relatively high rate of injuries to the shoulder complex. The amount of mobility allowed by the shoulder joint comes at an exchange of decreased stability. Evidence also suggests that the shoulder, which is traditionally a nonweight–bearing joint, has to assume the role of a weight-bearing joint during repetitive lifting (24). Furthermore, researchers have hypothesized that most weight-training programs emphasize the strengthening and hypertrophy of large muscle groups and subsequently neglect smaller scapular stabilizers (14,23); this may lead to muscular imbalances that may eventually predispose weight-training participants to shoulder injuries. Additionally, common resistance-training exercises frequently place the shoulder in injury-prone positions such as shoulder abduction with external rotation (12).

The purpose of this article is to provide the strength and conditioning professional with knowledge about the common injuries to the shoulder complex during resistance training as well as exercises that may predispose individuals to potential injury due to the biomechanical demands placed on the shoulder with these exercises. Furthermore, the article will provide the strength and conditioning professional with biomechanical exercise modifications that will make certain exercises safer and just as effective at achieving the goal to strengthen the upper extremity. Finally, a brief overview of preventive measures that can be implemented in a strength and conditioning program for the shoulder will be discussed. The information in this article may help the strength and conditioning specialists improve the work they perform in conjunction with medical professionals in helping athletes prevent injuries to the shoulder.


Multiple types of injuries have been reported with strength training. According to Lavallee and Tucker (30), strength-training injuries can be categorized as acute nonemergent (i.e., muscle strains, ligament strains), acute emergent (i.e., fractures, dislocations, and tendon ruptures), and chronic (i.e., tendinopathies, stress fractures). Evidence suggests that 46–60% of all acute injuries sustained in strength training are muscle strains and ligament sprains (5,22). In the shoulder, various types of injuries have also been reported with resistance training. The prevalence and types of injuries observed in strength training are typically dependent on the exercise selection and load used by different strength-training programs (30). Table 1 summarizes some of the common shoulder injuries as a result of strength training that have been reported in the literature.

Table 1
Table 1:
Common strength-training–related injuries to the shoulder (2–4,6,8,10,13,14,16,25,31,33,38,41,42,44,47)


Some commonly performed strength-training exercises may place the shoulder at risk. Specific exercises that have been associated with injuries to the shoulder are identified in Table 1. Several authors discuss exercises that place the shoulder joint in the “high five” position as potentially hazardous to the shoulder joint because of the increased stress placed on the anterior shoulder (12,14,24,26). The “high five” position is defined as the shoulder in 90° of external rotation simultaneously with 90° of shoulder abduction (Figure 1). Repeatedly placing the shoulder in this “high five” position with heavy loads may contribute to hyperlaxity or instability to the static glenohumeral ligamentous-capsular restraints (14,24,26). Jobe and Kvitne (19) suggested that when increased laxity or instability occurs at the shoulder, the dynamic rotator cuff muscles likely exert a greater force to stabilize the humeral head. This repetitive dynamic compensation of the rotator cuff may result in fatigue followed by tendinosis and pain in the rotator cuff.

Figure 1.
Figure 1.:
The “high five” position. This position may make the shoulder vulnerable to injury.

There are other commonly performed resistance-training exercises that may place the shoulder joint at risk. Reeves et al. (37,38) suggested that exercises placing the shoulder in a position of extension past the trunk could also contribute to anterior shoulder instability and rotator cuff injuries. Similarly, Haupt (16) associated osteolysis of the distal clavicle with the bench press during the eccentric phase of the exercise when the shoulder is extended posterior to the trunk due to the repeated microtrauma at the acromioclavicular joint.

Other exercises that may predispose the shoulder to injury are those in which the shoulder is internally rotated during shoulder abduction (e.g., lateral deltoid raises). In a study investigating characteristics of shoulder impingement in the recreational weight-training population, Kolber et al. (25) concluded that avoiding the performance of the upright row and lateral deltoid raises beyond an angle of 90° of shoulder abduction could potentially reduce the likelihood of sustaining shoulder impingement. Hawkins and Kennedy (17) reported if the shoulder is internally rotated during scapular elevation, the greater tuberosity of the humerus impinges the rotator cuff tendons and bursa against the acromion.


To successfully strengthen and hypertrophy the muscles of the upper body without predisposing athletes to shoulder injury, it is important for the strength and conditioning professional to provide athletes with safer exercise alternatives that are effective in achieving the athlete's goals. Furthermore, if athletes are recovering from a shoulder injury the strength and conditioning professional should be able to provide the athlete with pain-free range of motion exercises or exercise modifications that will facilitate their return to a normal level of function; this should be accomplished in conjunction with other medical professionals such as certified athletic trainers, physical therapists, or physicians. Understanding the underlying biomechanics of the shoulder will help the strength and conditioning professional provide appropriate guidance to athletes. Table 2 provides an overview of effective exercise modifications or alternatives that still target the appropriate musculature with less stress on the commonly injured shoulder structures.

Table 2
Table 2:
Summary of biomechanical shoulder exercise modifications and alternatives


The bench press is a commonly performed exercise among athletes that is often used as a 1 repetition maximum to assess upper extremity strength. Although there are benefits that can be gained from this compound exercise, the risks described in the previous section may contribute to shoulder injuries. To reduce the risks, several exercise modifications and exercise alternatives exist to make the exercise safer.

Alternating the spacing of the hands from a wider grip to a grip, no wider than 1.5 times the biacromial width (Figures 2 and 3) has been suggested to reduce the peak torque in the pressing motion and thus reduce the demand placed on the rotator cuff and the biceps tendon to stabilize the head of the humerus (15,49). The closer hand position has also been suggested to allow the athlete to keep the shoulder abducted to less than 45° throughout the range of motion as well as prevent it from exceeding 15° of shoulder extension when the bar reaches its lowest point (12). The alteration in the amount of shoulder abduction from the closer hand placement allows the clavicular border of the pectoralis major and the biceps brachii muscles to gain a mechanical advantage to aid in shoulder flexion through the initial and middle range of motion; furthermore, a decrease in stress occurs on the long head of the biceps muscle at the bicipital groove as the shoulder moves into horizontal adduction (1,12,29,36). In addition to these benefits, the literature has suggested that keeping shoulder abduction below 45° reduces the compressive forces at the distal clavicle and alters the touch position at the bottom of the movement to a point more superior to the xiphoid process that reduces the net torque on the shoulder (12,15,32).

Figure 2.
Figure 2.:
Wider grip bench press. When the hands are placed greater than 1.5 times the biacromial width, there is more demand on the rotator cuff and the biceps tendon. Notice that the shoulder approaches 90° of abduction.
Figure 3.
Figure 3.:
Closer grip bench press. When the hands are placed less than 1.5 times the biacromial width, there is less demand on the rotator cuff and the biceps tendon. Notice that the amount of shoulder abduction is less than 45°.

Another effective modification reported in the literature to reduce the stress on the shoulder during the bench press is placing a towel roll or pad 4–6 inches thick over or under the shirt (Figures 4 and 5) while performing the exercise (11,12). Performing this modification provides a visual and tactile cue to the athlete as to the distance the bar should travel during the eccentric portion of the movement. Furthermore, it prevents the shoulder from extending past the trunk which has been suggested as a movement to avoid to decrease injuries to the rotator cuff and acromioclavicular joint as well as reduce anterior instability (16,37,38).

Figure 4.
Figure 4.:
The bench press with no towel or pad. When the shoulder extends beyond the plane of the body, there is a higher risk for injury.
Figure 5.
Figure 5.:
The bench press with a towel or pad. The shoulder does not extend beyond the plane of the body and may decrease injuries to the rotator cuff, acromioclavicular joint, and the anterior shoulder structures.

Using a barbell hand-off from a spotter is another strategy that may be implemented to help reduce the likelihood of injuries to the shoulder. The literature suggests that the hand-off should be used for every set performed for the bench press, inclusive of warm-up sets (12). According to Fees et al. (12), the barbell hand-off may reduce the risk of shoulder subluxations or dislocations during the removal or return of the bar back to the rack position.

Various exercise alternatives or variations may also be implemented that target the musculature in a similar fashion. One example is the underhand grip (reverse grip) bench press where the hands are on the bar in a fully supinated position (Figure 6). This exercise places the shoulder in a position of relative external rotation which subsequently puts the long head of the biceps tendon under the acromion and rotates the supraspinatus muscle posteriorly away from the acromion (12,35). Conversely, the traditional overhand grip bench press places the shoulder in a position of relative internal rotation and places the biceps tendon out from under the acromion while positioning the supraspinatus directly under the acromion (9,12). Despite the biceps tendon being placed away from the acromion, the full forearm pronation of the overhand bench press stresses the attachment of the long head of the biceps during the exercise (12). It is also important to comprehend that if a structure is directly under the acromion, it is potentially at risk from mechanical abrasion if the athlete has a hooked (type III) acromion (12) or if the structure itself is inflamed.

Figure 6.
Figure 6.:
The reverse grip bench press. This exercise places the shoulder in a position of relative external rotation which subsequently puts the long head of the biceps tendon under the acromion and rotates the supraspinatus muscle posteriorly away from the acromion.

Another exercise alternative is the use of the decline bench press. Durall et al. (11) and Fees et al. (12) both reported that throughout the movement of a decline press, the shoulder is kept in a safe position below 90° of flexion and 45° of abduction with neutral external rotation. Unlike the decline bench press, the incline barbell bench press should be prescribed with caution as the “high five” position is maintained throughout the exercise and increases the strain on the anterior middle and anteroinferior glenohumeral ligaments (12,14,34). Athletes with anteroinferior shoulder instability should perhaps consider avoiding this exercise all together.

The modified bench press bar (Figure 7) provides another alternative method to perform the bench press. The modified bench press bar allows the shoulder to be kept in a position of approximately 45° of abduction which provides the same benefits as described with the closer hand placement of the barbell bench press. One of the advantages of the modified bench press bar over the traditional barbell is that the hand and wrist maintain a more neutral position and remain in alignment of the forearm and the humerus throughout the movement. Furthermore, this movement pattern is more specific to sports such as football where offensive linemen block defensive players in a plane similar to that provided by the modified bench press bar.

Figure 7.
Figure 7.:
The modified bench press bar. The shoulder is kept in a position of approximately 45° of abduction which decreases the demand of the rotator cuff and biceps tendon. The hand and wrist also maintain a more neutral position that is easier on the wrists.

Using dumbbells is another alternative to using a barbell for chest pressing motions. Dumbbells allow the athlete more freedom in terms of finding a pain-free range of motion. Hence, it is easier to avoid at risk positions such as the “high five” position with the dumbbells than with a barbell. Because of the increased control the athlete has with dumbbells, Durall et al. (11) recommended using them as a potential alternative even in a relatively higher risk exercise such as the incline press. Evidence suggests that using dumbbells instead of barbells may require individuals to control and balance the weights independently and potentially alter the involvement of the agonists, synergists, stabilizers, and antagonists (39). Both Welsch et al. (48) and Saeterbakken et al. (40) reported similar electromyographic (EMG) activity in the pectoralis major and anterior deltoid in dumbbell chest presses compared with barbell although dumbbell loads were 63–83% of the barbell loads. Because lighter loads may be used with dumbbells without hindering EMG activity in the target musculature as compared with using a barbell, this could prove to be advantageous to those athletes returning from an injury.


The chest fly is an exercise commonly performed to target the chest and anterior deltoid musculature. Similar to the bench press, lowering the shoulder past the trunk of the body should be avoided to decrease injuries to the rotator cuff and acromioclavicular joint as well as reduce instability to the anterior shoulder structures (16,37,38). Durall et al. (11) suggest that excessive horizontal abduction should be avoided when performing this exercise to avoid stress to the anterior capsule. To accomplish this, cueing the athlete to lower their elbows to their mid or posterior trunk at the bottom of the movement could prove to be an effective strategy (Figures 8 and 9). If the athlete requires a tactile cue to successfully avoid excessive horizontal abduction, the athlete may be placed supine on the floor to perform the exercise so that the floor serves as the tactile cue when the elbows make contact with the floor. Durall et al. (11) recommend that the elbows should be kept inferior to shoulder level to reduce shear across the subacromial space (which may irritate the rotator cuff tendons and bursa); they suggest to advise the athlete to begin the movement with the elbows slightly inferior to the shoulders and maintain the elbows in that position throughout the movement.

Figure 8.
Figure 8.:
Chest fly with the elbows horizontally abducted past the trunk of the body. When the shoulder extends beyond the plane of the body, there is a higher risk for injury to the shoulder.
Figure 9.
Figure 9.:
Chest fly with the elbows horizontally abducted to the plane of the body. When the shoulder does not extend beyond the plane of the body, there is a decreased risk in injuries to the anterior shoulder.

Another exercise alternative is to perform the exercise with adjustable cable pulleys in place of dumbbells or a machine. Unlike dumbbells, the cables provide a constant level of tension throughout the range of motion yet provide various range of motion angles because the exercise can be performed in standing at various body and shoulder positions or on a bench in a similar position as the dumbbell fly. The various shoulder angles and body positions available with the adjustable cable pulleys for the chest fly exercise can help the strength and conditioning professional to identify pain-free range of motion movements for the athlete for this exercise that also avoid high-risk shoulder positions such as excessive horizontal abduction and the “high five” position.


The overhead (military) shoulder press is an exercise that is sometimes performed behind the neck (Figures 10 and 11). The behind the neck version of the exercise places the shoulders in the risky “high five” position. To avoid this position, Durall et al. (11) recommend to instruct the athlete to maintain the hands and elbows anterior to the shoulder during the movement when using either barbells or dumbbells. If a shoulder press machine does not allow the athlete to keep their hands and elbows anterior to the shoulder, Durall et al. (11) suggest to place the athlete facing backward on the seat to avoid the “high five” position.

Figure 10.
Figure 10.:
The behind the neck military press. This exercise places the shoulder in the at risk position.
Figure 11.
Figure 11.:
Military press to the front. This safer alternative keeps the shoulders in a safer plane throughout the movement.

Dumbbells are also a good alternative for the shoulder press. Similar to the chest press, the use of dumbbells offers the advantage of more freedom to find a pain-free range of motion. Furthermore, Saeterbakken and Fimland (39) reported increased neuromuscular activity in the deltoid muscle using dumbbells over barbells in the shoulder press despite the dumbbell shoulder press having a lower 1 repetition maximum strength value as compared with the barbell shoulder press.


Similar to the shoulder press, the behind the neck variation of the lat pull-down is sometimes performed by athletes and potentially places the shoulders at risk due to the stresses placed on the shoulder with the “high five” position. Instead of performing this exercise behind the neck, the lat pull-down to the front is a viable alternative. Sperandei et al. (46) reported that the EMG activity of the target muscle (latissimus dorsi) was the same when performing the exercise behind the neck compared with the front and concluded that the pull-down to the front is a better choice. Furthermore, they suggested that the V-bar lat pull-down, which places the hands in a close grip position with a neutral grip, could be used as an alternative exercise.

Another lat pull-down variation reported in the literature is the modified lat pull-down to the front (Figure 12). Fees et al. (12) described the modified seated lat pull-down where the torso is reclined in 30° of trunk extension and the bar is suspended at arms' length in line with the xiphoid process. Using a grip of 1.25–1.5 times the biacromial width, the bar is pulled from overhead to slightly above the xiphoid process in the sagittal and coronal planes. Fees et al. (12) suggest that this modified version of the lat pull-down to the front places a greater emphasis on the scapular retractor and latissimus dorsi muscles as compared with the behind the neck variation of the exercise.

Figure 12.
Figure 12.:
The modified lat pull-down. This modification of the exercise has been suggested to place a greater emphasis on the scapular retractor and latissimus dorsi muscles as compared with the behind the neck variation of the exercise.

The underhand (supinated) grip lat pull-down is another alternative to the behind the neck lat pull-down. The supinated grip, as previously discussed, puts the long head of the biceps tendon under the acromion and rotates the supraspinatus muscle posteriorly away from the acromion (12,35); hence, it may be a good alternative for those athletes recovering from primary shoulder impingement syndrome. Fees et al. (12) recommend implementing this exercise as part of a pain-free range of motion progression to lead to a front lat pull-down.


The lateral raise and the upright row are excellent exercises to strengthen the middle deltoid, supraspinatus, and the upper trapezius. Because the traditional performance of these exercises require simultaneous elevation and internal rotation of the shoulder as the arm goes to shoulder level and beyond, the greater tuberosity of the humerus may impinge the rotator cuff tendons or the subacromial bursa against the acromion (17). The repetitive nature of this movement may lead to shoulder impingement or tears to the rotator cuff. Kolber et al. (25) investigated the characteristics of shoulder impingement in the weight-training population among 77 men and reported that a significant association existed between clinical characteristics of shoulder impingement and performing the lateral deltoid raise and the upright row above 90° of shoulder abduction. In prescribing these exercises with asymptomatic individuals, the strength and conditioning professional may cue athletes to keep the shoulder below the 90° mark of shoulder abduction during the exercises (Figures 13 and 14). In athletes recovering from shoulder impingement or other rotator cuff pathology, strength and conditioning coaches may opt to instruct athletes to eliminate the upright row altogether and to substitute the traditional lateral raise exercise with the movement in the scapular plane (30° anterior to the frontal plane) with the shoulders externally rotated (Figure 15) in an effort to maintain the size of the subacromial space during the motion (43).

Figure 13.
Figure 13.:
The lateral raise to 90° of abduction. Raising the arms to no more than 90° of shoulder abduction may decrease the risk of shoulder impingement.
Figure 14.
Figure 14.:
The upright row to lower-/mid-chest line. Modifying the range of motion of this exercise to mid-chest helps to keep the shoulder to no more than 90° of shoulder abduction and may decrease the risk of shoulder impingement.
Figure 15.
Figure 15.:
The scapular plane side raise. The modification of the side raise to the scapular plane can maintain the size of the subacromial space during the motion to help prevent shoulder impingement.


The snatch and the clean and jerk are weightlifting exercises prescribed by strength and conditioning coaches to help improve power output with their athletes. Although these are excellent exercises, it is important to note that the ballistic nature of the movements creates a potential hazard for the athlete. Because the exercises require the athlete to accelerate the weight quickly while generating maximum power and velocity, this can place the athlete at risk. Levallee et al. suggest that the jerking and rotational movements of these lifts may cause dislocations, tendon ruptures, and fractures (30). Furthermore, Lavalleee et al. suggest that when the shoulder is placed in the “at risk” position of extreme shoulder flexion and abduction, such as in the snatch, rotator cuff injuries or supporting musculature strains may occur (30).

To avoid the “at risk” position of the shoulder all together, the power clean, the hang clean, and the high pull (to just below 90° of shoulder abduction) are good alternatives to the snatch and the jerk to develop power without placing the shoulder in the “at risk” position. With athletes recovering from rotator cuff tendinosis or subacromial impingement, the strength and conditioning coach may want to start the athlete with a kettlebell swing where they can practice the triple extension component of the movement without having to put the shoulder in the upright row position during the execution of the power clean or the power clean derivatives. These modifications are easy to implement for both the athlete and the strength coach.


In an effort to avoid injuries to the shoulder, the strength and conditioning professional should be familiar with predisposing factors that may put strength-training athletes at risk. Kolber et al. (23) reported that recreational weight-training participants had decreased mobility for active range of motion in shoulder flexion, abduction, and internal rotation as compared with controls who did not participate in resistance training. Conversely, weight-training participants had increased active range of motion for shoulder external rotation as compared to the control group. Furthermore, the weight-training participants had greater posterior shoulder tightness and larger agonist to antagonist muscular imbalances as compared to the control group. Kolber et al. (23) reported that the findings in their investigation suggest that the recreational weight-training population is predisposed to strength and mobility imbalances that have been associated with shoulder disorders. The authors suggested that recreational weight-training participants may bias their training toward the larger muscle groups such as the pectoralis or deltoids and neglect the smaller muscle groups such as the scapular stabilizers and rotator cuff that are responsible for stabilizing the scapula and rotating the glenohumeral joint; this likely contributes to the imbalances observed. Evidence of these imbalances and their propensity to contribute to shoulder pathology have been reported among weight-training participants with subacromial impingement (27). A shoulder screening process for coaches to use with athletes to assess an athlete's suitability for overhead lifting exercises as recommended by Howe and Blagrove (18) is a tool to use in order to help prevent shoulder injuries. Furthermore, it is recommended that the strength and conditioning coach implement exercises that target the lower trapezius, middle trapezius, serratus anterior, and external rotators to improve the balance between the larger muscle groups and the smaller stabilizing muscles. Additionally, stretching exercises that address posterior shoulder tightness such as stretching the shoulder into internal rotation and stretching of the posterior shoulder capsule could prove to be beneficial.


The shoulder is a complex joint that sacrifices stability for a great amount of mobility. The repetitive nature of strength training, along with the compromising positions in which the shoulder is placed in many traditional strength-training exercises, makes the shoulder joint susceptible to a variety of injuries. Understanding the biomechanical modifications to certain exercises can help the strength and conditioning coach become better prepared to assist athletes in avoiding injuries to the shoulder as well as assist athletes in recovering from shoulder injuries. It is recommended that strength and conditioning coaches provide appropriate screening for athletes before initiating overhead activities that may help to find mobility and strength imbalances that may predispose them to injuries. Once these imbalances are located, the strength and conditioning coach should prescribe appropriate exercises to help correct the imbalances and ensure that training is well-balanced between the larger muscle groups and the smaller stabilizing muscles of the shoulder region so that the likelihood of injuries is decreased. If an athlete is recovering from a shoulder injury, it is essential that the strength and conditioning coach to work closely with the medical staff to ensure there is continuity of care among all members of the sports medicine and sports performance enhancement personnel.


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    bodybuilding; powerlifting; resistance training; shoulder disorder; shoulder injury; weightlifting

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