If you work in an orthopedic clinic chances are you see plenty of people with rotator cuff related shoulder pain (RCRSP). Call it impingement, tendinopathy, strain, tear, subacromial pain, whatever you want to call it – it’s a common presentation for many therapists.
For the weight training population, pressing exercises, despite being among the most popular exercises, can be provocative and sometimes difficult to return to for people with RCRSP. In this piece I outline a progression I use and have had success with in returning people with RCRSP to pressing in the weight room. As a disclaimer, to the best of my knowledge there is no research that supports or refutes my strategies.
Before starting this program I set several prerequisites that I believe are required to begin pressing:
- Pain-free shoulder flexion and abduction to 90 degrees, and full pain-free shoulder horizontal ABD and ADDuction
- No difficulty and no more than minimal pain performing basic scapular exercises (i.e. rows) and basic rotator cuff strengthening exercises.
Side note: I like the vast majority of cases to be pain-free with the above activities before starting this progression, but in some chronic cases with whom pressing is identified as a goal activity I may start this progression a bit earlier, as long as pain is at a mild level and isn’t exacerbated in the long-term by any of these activities. As with any client, this depends on individual factors.
Without further ado, here is my progression series:
1) Standing One Arm Cable Press
This is a gem I learned from Stu McGill that incorporates pressing and anti-rotation core control. It’s not an overloading exercise that I’d recommend someone use to build their pecs and/or their bench press, but I like it as an entry to pressing exercise for someone who’s dealing with RCRSP.
Here’s a video of the exercise I shot in 2016 for my contribution to an article on Zach Long’s The Barbell Physio website (1).
2) Dumbbell Floor Press
With all bench pressing I prefer to have people start in a slight elbow tuck. Instead of having the arms right out at the sides at 90 degrees abduction I like to see more of a 45 degree angle between the torso and the arms. I also like to see the dumbbells come together and almost touch at the top.
The reduced range of motion that a floor press provides is often more tolerable for the patient than a full range of motion bench press, hence why I like to start with the floor press first.
3) Dumbbell Bench Press
Similar to the floor press – just with a slightly larger range of motion.
4) Push-up Progression
I start people doing a push-up on the wall, then with their hands elevated on a counter, then on a bench or couch, and then to full push-ups from the floor.. If you have an adjustable therapy bed this technique works great.
Side note: the progression used by Tony Gentilcore and Michael Mash has push-ups done before dumbbell presses. For people with lower body weight and/or higher strength relative to body weight I agree with this. That being said, a lot of people I’ve worked with in these scenarios tend to be bigger clients so I use dumbbell presses first before progressing to push-ups.
5) Machine Bench
This is pretty self-explanatory. If you don’t have access to a machine bench press this step may need to be skipped.
5.5) Pin or Board Press
Normally most clients can move from 4) to 5) to 6) quite well, but I’ve found that some clients get stuck between push-ups and bench press. For the sake of not keeping clients from their goal activities for too long I’ve found these to be a nice intermediate between dumbbell presses and push-ups and full ROM bench pressing.
Pin and board presses are quite similar although in pin pressing you start with the bar just above chest height in the pins and press it to lockout from a dead stop. A good way to do this is using a smith machine if you have access to one.
By contrast, with a board press you unrack the bar (as you would normally with a bench press) and bring the bar down to the board (or you can set support bars/pins at a similar height if doing it in a power rack without boards) before pressing back up.
For pin and board pressing – set it to a height that is pain-free and gradually work down to the chest over time.
6) Barbell Bench Press
As above I coach any bench pressing with the arms slightly tucked in to reduce the load on the front of the shoulder. I do encourage scapular retraction & depression but do not coach a “powerlifting esque” style of back arch in the lift.
Some tips for this progression:
- During my subjective history I ask people what exercises they can still do in their training routine. It makes no sense having them do push-ups on the wall if they can do them from the floor properly and pain-free.
- Ideally I want everyone to be able to do each stage pain-free before progressing to the next one.
- I am OK with patients working through a little bit of pain as long as the pain stays the same with each repetition and doesn’t get worse. There’s a fair amount of research in tendinopathies that support exercising into some amount of pain during the rehab process. However I do want clients in the vast majority of cases (there are exceptions), to be able to perform the exercises pain-free before progressing to the next stage.
What about overhead pressing?
To shoulder press you should be able to do the above exercises with no pain and possess full shoulder range of motion. If you don’t possess full shoulder flexion range, landmine presses, or even incline presses, may be a better place to start.
Once your patient has full shoulder range I recommend the following progression:
- Bottoms-up kettlebell presses (if you have access to kettlebells in your clinic/gym)
- Palms facing dumbbell or kettlebell shoulder presses (referred by some as ‘hammer grip’ presses)
- Traditional dumbbell shoulder presses
- Barbell shoulder presses
I hope this piece gives you some ideas on how to return your patients who weight train and are dealing with RCRSP back to pressing exercises in a safe and effective manner. As always, thanks for reading!