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February 17, 2019

How to Train Around Overhead Press Shoulder Pain

How to train around overhead press shoulder pain

Shoulder pain with an overhead press motion is extremely common. As a physical therapist, I saw many, many patients with this complaint. The cause can vary (i.e. reactive impingement, tendonopathy, frozen shoulder, nerve compression), but my recommendations tend to be similar: learn the difference between a horizontal and vertical push, assess your range of motion (ROM) abilities, and choose exercises that feel best for you.

Let's begin with step one: learn the difference between a horizontal and vertical push.

Within the fitness industry, we categorize push exercises within two categories: horizontal push or vertical push.  Both have their place and one isn’t superior to the other. Both are important and target different muscles through different ranges of motion. Ideally, you’d program exercises in both categories within your training program, however there are some cases where one would be preferred over the other. There are so many questions and things to consider…I know, I know! Let me go into detail about what horizontal and vertical push exercises are. Then we will dive deeper into why one category may be more comfortable for some people with shoulder pain or discomfort. 

First, what is a push exercise? It’s any exercise where you’re pushing a force away from the body. Push exercises generally target the chest and shoulder muscles. 

The category of horizontal or vertical describes the position of the arms in relation to the torso. 

  • If you push the arms and they’re perpendicular to the torso, it’s a horizontal push. 
  • If you push the arms and they’re parallel to the torso, it’s a vertical push. 
  • Horizontal Push

    It helps immensely to see examples. Here are some examples of horizontal push exercises. As you can see, the perpendicular arm position is in relation to the torso, not the ground. Regardless of whether you’re doing a press supine or standing, it’s still a horizontal push. As you can see, horizontal push exercises primarily target the chest. They also work the triceps secondarily.

    • Supine DB chest press
    • Chest press machine
    • Push-up

    Vertical Push

    Now, here are some examples of vertical push exercises. As you can see, the parallel arm position is in relation to the torso, not the ground. Vertical push exercises primarily target the shoulders. 

  • Band overhead press
  • Military press
  • Pike push-up
  • Let’s talk about general shoulder range of motion (ROM) now. As you can see in the photo below, the shoulder generally goes from being at 0 degrees at your side all the way up to 180 degrees overhead (some people have even more). 

    Shoulder flexion ROM

    Learn how to assess your shoulder active range of motion

    Stand in front of a mirror facing one side and raise your arm overhead. Approximately how much shoulder ROM do you have on each arm?

    Some people may not have 180 degrees of shoulder flexion on one or both arms. Is that you? Why? Some possible causes of limited overhead ROM include:

    1. tight capsule (frozen shoulder)
    2. tight muscles (lats)
    3. disuse (inactive and not working end-range )
    4. excessive shoulder rounding posture (tight pecs and/or limited thoracic extension)
    5. pain
    6. bony anatomical block
    7. past injury/surgery

    Let’s talk some of those causes through now. 

    The first 5 causes are issues we can fix or improve upon. If someone has a tight capsule, well mobilize it. If some has a tight muscle, well stretch it. If someone has avoided or not done overhead reaches in a while, well get back to practicing it. If someone can’t raise the arms overhead because of excessive shoulder rounding, well pull the shoulders back first before raising the arms. If it’s pain that’s limiting you, well slowly re-introduce yourself to this movement over time to increase tolerance to it. This is the best-case scenario. If you have <180 degrees and you fall into one of these 5 categories, you can work on it and improve it. I’ll show you how. 

    All of those causes of difficulty with full overhead shoulder flexion ROM can be fixed. The only two that can’t include bony abnormality (like a bone spur) or a past injury or surgery that’s already been rehabbed and simply has gone as far as possible. Then you have to learn to work within your available range – that’s no problem!

    Let’s think back to our two categories of push: horizontal and vertical. Which category would be easier for someone to do that has limited shoulder flexion ROM?

    If you guessed horizontal, ding ding ding, you’re right! Horizontal push exercises only required 90 degrees of shoulder flexion. So, you’re golden! They are going to be the best option for people who have shoulder pain or discomfort, especially in the overhead range. Start there. They should be able to do all of those exercises to some extent, unless of course they’re limited in another direction of ROM and that would take me on another tangent. 

    What would happen if I were to program an overhead military press for a client who only has 150 degrees of shoulder flexion in one or both shoulders? They’d likely be unable to or they'd have discomfort or pain and would exhibit compensatory patterns like excessive lumbar extension aka arching the lower back (as seen in the photo below).

    Shoulder flexion ROM

    Choose exercises that are most comfortable for you

    This is where you have to back, back, back it up. Work within your abilities. Start by working through a variety of horizontal push exercises. There’s lots of options! Try out different sets, reps, tempos, isometrics, eccentrics, and equipment variations to progressively overload over time.

    In addition, you should be doing some mobility work to improve your shoulder flexion ROM. Below are some of my favorite shoulder flexion mobility exercises:

  • Foam roll wall slides
  • Kneeling bench t-spine extension
  • Foam roll child’s pose
  • Foam roll alt. shoulder flexion
  • Band standing 1-arm lat stretch
  • Once you’ve spent some time stretching the lats and mobilizing the shoulders & thoracic spine, re-test! See if your shoulder flexion ROM is any better! As long as it’s one of the causes 1-5 that we discussed earlier, I’m confident it will have improved.

    So is it time to introduce the vertical push exercises now? Not quite. Slow your horses.

    Let’s say you have increased shoulder flexion ROM now, but it’s still not 180 degrees. Well, it may be a good time to work your way up: baby steps.

    I like to call them the “In between” exercises: exercises that are in between horizontal and vertical. Here are some examples:

  • Incline DB press
  • Landmine press
  • As you can see, they require somewhere around ~120 degrees or more of shoulder flexion. They’re a good way to progress toward the full overhead vertical push exercises. You can progress the amount of shoulder flexion range you strengthen within over time for both of these exercises. For example, with the incline dumbbell chest press, consider beginning with a 30-degree bench incline, then progress to 40, then 50, then 60, then 70, etc.

    horizontal vertical push

    Let’s say you start incorporating these into your training program, while still continuing to do your stretch and mobility work to get closer to that 180 degrees. Your goal should be between 170-180 degrees of shoulder flexion - which is functional. Once you get there, you should be ready to move onto the vertical push exercises…finally!

    Remember your normal exercise progressions. Start with some light load, high rep band work. Once that’s feeling okay, progress to DB’s or BB’s at high reps with a light load. Then, once you’re confident with that, start to push for strength gains and switch to heavier load and lower reps. Eventually you can progress even more by adding a pause, accentuating the eccentric, or using even more ROM.

    If at any time you notice some discomfort, take a step back, regress for a little bit, and then try to progress again when you feel comfortable.

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    modify your workouts around your abilities

    Wrap up

    To wrap up, keep in mind this is a very generalized approach. I’m not taking into account other confounding variables, other injuries you may have, etc.  

    I hope that what you take away from this is knowing the difference between horizontal vs vertical push exercises, howing how to assess your ROM, knowing how to improve shoulder flexion ROM, and discovery of a natural way to progress back into overhead press movements progressively.

    Of course, there are going to be unique scenarios. If that’s the case, you may want to consult your physician or get an assessment by a physical therapist for further diagnosis and treatment ideas specific to your needs.

    In general, this is how I approach exercise programming for a client who struggles with overhead presses due to shoulder discomfort and limited ROM. I hope you found this helpful! 

    beautiful to the core
    horizontal vertical push

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