Advanced bodybuilders and weightlifters subject their bodies to tremendous amounts of stress. In many cases, the stress produced by training with extremely heavy weight leads to some type of injury, everything from mild muscle pulls and tendonitis to server sprains and tears.
Certain structures in the body are likelier to suffer damage under the assault of heavy training than others, and one of the areas most vulnerable to injury is the shoulder joint. The shoulder is the most complex and most mobile joint in the body, but this mobility is gained at the cost of instability and it is this inherent skeletal instability that renders the shoulder so susceptible to injury.
STRUCTRE OF THE SHOULDER
To understand why this is so, what sort of shoulder injuries bodybuilders are likely to encounter, how to prevent them and what to do about these injuries once they have occurred, let's start by examining the anatomy of the shoulder. To begin with, the fundamental structure of the shoulder girdle includes the scapula, which is the large triangular shoulder blade situated on either side of the upper back, and the clavicle, the collarbone, which attaches at one end to the sternum, the upper part of the ribcage at the center of the body and at the outer end to a structure at the top of the scapula called the acromion, which forms the bony top or point of the shoulder.
To render the entire shoulder girdle mobile, as well as allowing the arm virtually 360 degrees of rotation at the shoulder, there is not one joint involved, but three joints, plus one "articulation." These are:
- The Glenohumeral Joint. This is the ball-and-socket joint that most people think of as the shoulder. The top of the humerus, the upper arm bone, fits into a shallow cavity or socket situated below the acromion called the glenoid.
- The Acromioclavicular Joint. This is the point at which the outer end of the clavicle is joined to the acromion at the top of the shoulder.
- The Sternoclavicular Joint. This is where the inner end of the clavicle attaches to the sternum.
- The Scapula. The shoulder blade is attached to the thorax by a variety of muscles and other tissues that allow it movement in relationship to the trunk. It forms a joint with the arm at the glenohumeral joint and with the clavicle at the acromioclavicular joint.
Injuries can occur to any of these areas, but the most common problems encountered by bodybuilders and weightlifters involve the glenohumeral joint and the acromioclavicular joint.
INJURIES TO THE GLENOHUMERAL JOINT
The glenohumeral, ball-and-socket joint of the shoulder is very different from a ball-and-socket joint such as the hip in that, as described above, it has a tremendous amount of additional mobility It achieves its mobility from the fact that there is very little bony contact between the head of the humerus and the glenoid socket. At any given position, only about one quarter of the head of the humerus is in contact with the glenoid, which is what makes this joint so inherently unstable.
What stability it has comes from the surrounding ligamentous tissue that holds the joint together. Particularly the capsule, which is a fibrous envelope that attaches circumferentially around the glenoid, and is reinforced anteriorally by the glenohumeral ligaments.
Reinforcing the capsule and ligaments is the rotator cuff a musculotendinous support structure overlying and intimately attached to the capsule. The most important part of this structure in terms of frequency of injuries is the supraspinatus tendon.
Injuries to the glenohumeral joint almost always involve some damage to one or more of the ligaments, the associated tendons and muscles, or the glenoid labrum, a fibrocartilaginous structure at the rim of the glenoid cavity. The most frequent types of glenohumeral injuries are:
- Damage to the capsule and ligaments, commonly where they attach to the rim of the glenoid. Tears or ruptures of these tissues result in pain and eventually in loss of mobility.
- Damage resulting in anterior (meaning to the front) instability, in which sufficient stretching or tearing of the tissue allows the end of the humerus to come out of the glenoid cavity Subluxation is when the head of the humerus temporarily slips onto the rim of the glenoid and then spontaneously slips back into the socket; dislocation occurs when the head of the glenoid slips out over the glenoid rim and stays in this position.
- Damage to the rotator cuff, usually as a result of impingement syndrome, a chronic, inflammatory process of the rotator cuff and the suhdeltoid hursa as these structures repeatedly impinge, are pressed and squeezed against the underside of the roof of the shoulder joint. Repetitive microtrauma and overuse of this nature may result in inflammation, partial tearing and thickening of the rotator cuff.
- Bursitis, inflammation of a hursa, which is a sack that allows for the smooth gliding motion between the rotator cuff and the upper end of the humerus and the overlying deltoid muscle and the roof of the shoulder joint.
INJURIES TO THE ACROMIOCLAVICULAR JOINT
The most common injuries to bodybuilders and weightlifters in the area of the acromioclavicular joint involve damage to the ligamentous tissue surrounding and stabilizing the joint and arthritis degeneration of the joint itself.
A shoulder separation involves a situation in which some degree of subluxation or dislocation occurs between the clavicle and the acromion in the area of the AC joint. This type of injury, often caused by falling on the point of the shoulder, is more common to athletes like football players than to bodybuilders.
The two exercises that I see causing the greatest frequency of injuries to the AC joint in bodybuilders are heavy bench presses and dips. These movements frequently cause cumulative microtrauma to the distal or outer end of the clavicle, resulting in destruction of the bony tissue in this area leading to degeneration of the joint.
HOW SHOULDER INJURIES OCCUR
While the shoulder joint is a skeletally unstable structure, it is connected to some of the most powerful muscles of the body. For example, a main function of the pectorals is to pull the shoulder girdle forward, while muscles of the back such as the rhomboids, latissimus dorsi and trapezius work to pull the shoulder girdle up, down and to the rear.
The joints of the shoulder are involved in almost all upper body movements. Stress is put on the shoulder not only when you're training the deltoids, but during chest, back and arm workouts as well. Therefore, one of the primary causes of shoulder problems is simply overuse. When you overuse an area of the body there is a resulting degree of microtrauma. This damage, although small, can be cumulative. If you keep training in spite of fatigue and mild pain, the damage is made worse and eventually leads to inflammation or more serious damage and the likelihood of chronic or incapacitating problems in the area.
Damage can also be done by a single incident of momentary overstress, such as lifting too heavy a weight or a multiplication of stress that comes from using poor technique. Faced with a sudden stress the shoulder is not prepared to deal with, the ligaments and musculotendinous structures of the shoulder can stretch, tear or rupture. However, it is possible that what may appear to be an injury resulting from a single incident of overstress may actually be the result, in part, of cumulative microtrauma in the injured area due to repeated overuse of which you were unaware.
Certain exercises are likelier to cause shoulder injuries than others. For example, a lot of bodybuilders I've treated have sustained glenohumeral injuries from doing heavy bench presses. Advanced bodybuilders, who have built up a great deal of strength, are capable of lifting enormous amounts of weight, 500 pounds and more in the bench press, and this puts enormous amounts of stress on the shoulder joint stress that the inherently unstable shoulder joint was not designed to cope with. If the bodybuilder attempts this kind of lift when the shoulder joint is already weakened by overuse, or when it has become overly fatigued during a workout, the glenohumeral joint and its surrounding tissue may not be able to bear up under the demands of that much weight and he or she may experience some degree of acute injury
Also, certain exercises appear to be more biomechanically unsound than others, which means they must be approached with a great deal of care. For example, while I've never had a patient with a shoulder injury that could be directly traced to doing behind-the-neck barbell presses, this movement does put a lot of stress on the shoulder while it's in its least stable position. A conventional military or dumbbell press involves a combination of abduction and external rotation, which puts the head of the humerus against the weaker part of the shoulder joint, forcing it forward. Pressing behind the neck adds the element of extension, putting even more stress on the head of the humerus and causing it to bear large amounts of stress while in its relatively weakest and most vulnerable position.
But no matter what exercise you are performing, you are courting injury if you use poor technique or bad judgment. Bodybuilders who bounce too heavy a weight off their chest doing barbell bench presses, jerk the weight around and let it get out of control performing movements like barbell shoulder presses or dumbbell presses and flyes are simply asking for trouble. So are the ones who train too hard when they're already tired, or who fail to adequately stretch and warm up before a heavy workout.
PREVENTION OF SHOULDER INJURIES
Prevention of shoulder injuries involves nothing more for the most part than avoiding the mistakes outlined in the previous section. This involves:
- Proper stretching, keeping the structures flexible so that a sudden elongation due to pull of heavy weight will not create damage.
- Proper warm-up to allow the structures maximum ability to deal with stress.
- Using proper technique - controlling the weight, not letting stress become magnified by out-of-control inertial forces.
- Avoiding overtraining - both short and long term. Short-term overtraining means that you are stressing a fatigued area; long-term overtraining means that you are in danger of "overuse syndrome."
- Avoiding pain. If you feel pain, avoid whatever movement is causing it. Try something else - incline instead of flat, for example, dumbbells instead of barbells. But don't continue to do anything that causes you pain.
- Avoid biomechanically unsound exercises. If a movement involves putting stress on the joints at an especially awkward angle or when they're in an unstable position, the exercise should be approached with care.
Remember, when it comes to overuse and overtraining, that the shoulder is involved in virtually all upper body movements, not just deltoid training. While bench presses and behind-the-neck presses are the exercises most often associated with shoulder injuries, doing movements like heavy dumbbell flyes or laterals, weighted behind-neck chins or heavy pulldowns can also contribute to the wear and tear of the shoulder joints that can lead eventually to serious injury.
TREATMENT OF SHOULDER INJURIES
There are numerous specific programs of therapy appropriate to each of the various kinds of specific shoulder problems, such as bursitis, bicipital tendinitis, impingement syndrome, rotator cuff tears, labral tears, capsular disruption, or arthritic degeneration of the glenohumeral joint or the AC joint. However, while there are differences in how each of these conditions is treated, there are certain general therapeutic principles that apply to virtually all of them. These are:
- Treatment of inflammation
- Stretching and restoration of range of motion
- Avoidance of reinjury
The first step in rehabilitation of any shoulder injury is rest and avoiding the particular activity that caused the problem in the first place. I can't stress this enough. The idea of "training through the pain" is disastrous when it comes to physical injury. When a damaged structure is put under stress you only make the injury worse, prolong the period needed for recovery and possibly limit the degree of recovery you will ultimately be able to achieve.
In the event of inflammation caused by severe tendinitis or bursitis, the use of an oral anti-inflammatory drug may be indicated. But in cases where anti-inflammatory injections are administered, they must be used on a limited basis — once, twice or, at the most, three times spaced out over a period of time. If the anti-inflammatory injections are going to be effective, you usually expect to see a response in the first few days after their introduction. Repeat injections of anti-inflammatory drugs are not recommended, since they have a deleterious effect on collagen tissue.
Once the acute inflammation has subsided the next step is muscular and capsular stretching, a restoration of full flexibility in all the structures involved within the limits of pain. Stretching is important to avoid such problems as capsular adhesions. If range of motion is not restored, the result can be adhesive capsulitis, a severe restriction in the range of motion of the shoulder also called "frozen shoulder. However, in cases of glcnohumeral instability, you should avoid further capsular stretching in the same direction as the instability.
Following restoration of range of motion with problems such as interior instability, the next step is for strengthening such things as the internal rotators, the adductors, the anterior deltoid and the prime scapular stabilizers. Obviously, the specific exercises required for rehabilitation depend to a large degree on the nature of the injury itself. But whatever the particular therapy called for, the initial steps in strengthening involve very low weight, high-rep exercises, isolating the specific muscles you want to work — such as the subscapularis, the internal rotator of the shoulder or the anterior deltoid. Since extreme isolation of a given bodypart is often necessary, this is a situation in which a variety of specialized exercise machines is extremely valuable.
In the event of impingement syndrome and/or anterior instability, the restoration of strength is a particular priority. However, I recommend a substantial period of light, high-repetition rehabilitative exercise before going on to train with heavier weights — although in some cases the patient may never be able to regain pre-injury strength levels.
Dealing with most of my health-oriented patients, I have no great problem convincing them to go slowly and not to rush into heavy training too quickly. With bodybuilders, however, this is almost always a struggle. Bodybuilders and weightlifters are notorious for believing they know more than their doctors. Their instinct is to jump into heavy training at too early a stage, and they need to be constantly reminded that a few extra weeks of going slow will ultimately save them months or years in the rehabilitative process.
And when I say heavier resistance, I mean progressively heavier resistance. You don't go in one day from light training to heavy, one-rep maximum repetitions. The area to be rehabilitated needs to be strengthened gradually over a period of time. Remember, not only are you trying to rehabilitate an injury, you are dealing with a structure that was inherently weak enough to be injured in the first place. So gradual and careful escalation of poundages is an absolute necessity to avoid re-injury.
One important factor in understanding the process of rehabilitation of shoulder injuries is that the healing process can take a considerable period of time, depending on the severity of the injury. Really serious conditions such as severe anterior instahlity or substantial damage to the rotator cuff may involve as much as six months, nine months or even a year. However, less serious conditions such as mild inflammation are reversible within a relatively short period of time.
Although most injuries respond to the kind of conservative treatment described above, there are times when surgical intervention is called for, especially for professional athletes and young people with complete tears.
For example, in the case of a young pitcher or tennis player with a complete rotator cuff tear, you'd want to go in there immediately. In the event of extreme shoulder separation, sometimes it's necessary to go in and reattach the distal end of the clavicle to the acromion to restore the AC joint. In the case of arthritis of the AC joint, when conservative treatment is not sufficient, the surgical remedy is to cut away a small portion of the distal end of the clavicle.
Arthroscopic surgery, which is currently so widely used in knee injuries, has not as yet developed to the same degree in dealing with injuries to the shoulder. The arthroscope is used for diagnosis, and for procedures such as resecting torn portions of the lahrum, but not for rotator cuff repair. In terms of state-of-the-art orthopedics, there is nothing to replace standard open surgical procedures for rotator cuff tears.
THE LONG-TERM PROGNOSIS FOR SHOULDER TRAINING
The human body is not something that lasts forever. It is subject to cumulative damage from long-term wear and tear, and it eventually wears out. And when you subject the body to excessive amounts of stress, the degeneration and attrition are accelerated.
Bodybuilding for health and fitness can give you a body that is 10 or 20 years younger than that of a more sedentary person, given the variations inherent in individual heredity. But bodybuilding or weightlifting pursued as a serious sport takes a tremendous toll on the body, particularly on the joints. Especially the inherently unstable shoulder joint.
A race car, for example, can in a few hours wear out a set of tires that would last years on a regular car, and a high-performance dragster requires an engine rebuilding after every run. When you increase performance, you also increase stress, and the rate of wear and tear becomes vastly accelerated.
Most individuals don't begin to experience the problems associated with physical attrition until middle or old age. Serious athletes, particularly bodybuilders, often experience these kinds of problems earlier on. In fact, virtually every competition bodybuilder and weightlifter I've treated, even if quite young, has already experienced some physical problems, limitations of motion or chronic damage to the musculotendinous structures, joints or ligaments that in some way limited their ability to do certain movements or bear up under particular kinds of stress.
Most good competitors learn to 'train around" chronic problems. If it hurts them to do bench presses, they substitute dumbbell presses, or incline presses or something else. If a lower back problem prevents them from doing barbell rows, they switch to one-arm dumbbell rows or heavy cable rows, whatever it takes to work around the affected area.
When you've been training a considerable amount of time, training around a physical problem is usually possible because you already have gotten most of your growth and developed about the maximum amount of strength you're capable of. And since it's always easier to maintain a level of development than it was to achieve it in the first place, you may be able to get away with training around a considerable amount of damage and limitation.
But this is not always the case. Sometimes an injury to an area such as the shoulder is so great that you just have to quit heavy training. Stop completely, not for a rest, but forever. You only get to be a virgin once, and any time you sustain a serious injury, especially if surgery is required, no matter how much of your pre-injury physical ability you are able to regain, the injured area will never be "as good as new." And areas that have been injured in the past usually degenerate at an accelerated rate over time compared to noninjured areas.
But the real lesson this implies, I believe, is that bodybuilders who do not have any competitive ambitions should avoid the kind the damaging, heavy training that would-be World and Mr. Olympia competitors have to put themselves through. There's a physical price to be paid for pushing your body to its limits, and no reason to pay that price unless there is some commensurate reward to be gained for doing so.