Shoulder pain is a common issue that can disrupt training, daily life, and overall well-being. Whether it’s from lifting, an old sports injury, or simply sleeping in an awkward position, shoulder pain can be frustrating. Fortunately, most cases improve without the need for surgery, injections, or months of inactivity.
In this guide, we’ll break down why your shoulder hurts and how to approach rehab in a way that gets you back to enjoying the activities you love.
Basic Shoulder Anatomy
Before diving into why your shoulder hurts, it helps to understand how the shoulder works. The shoulder is a ball-and-socket joint made up of three main bones:
- Humerus (upper arm bone)
- Scapula (shoulder blade)
- Clavicle (collarbone)
These bones are supported by muscles, tendons, and ligaments. If you’ve experienced shoulder pain, you’ve probably heard of the rotator cuff. Think of the rotator cuff as a glove that surrounds the ‘ball’ portion of the ball-and-socket, as it plays a key role in stabilizing the joint. The muscles surrounding the shoulder blade also help move the shoulder effectively. We’ll come back to this later in the case study section.
Understanding Shoulder Pain
First, let’s clear up a common myth: pain does not always mean that things are damaged. Just because your shoulder hurts does not mean you have a torn rotator cuff, a labrum tear, or “bone-on-bone” arthritis. In fact, many people with these findings on X-rays or MRI scans have NO pain at all.
For example, one study looked at 123 individuals with one-sided shoulder pain and no pain in the other shoulder. Researchers performed MRI scans on both shoulders of each participant to compare findings between the painful and non-painful sides. They discovered many ‘abnormalities’, such as rotator cuff tears, labrum tears, and osteoarthritis in both shoulders, regardless of pain.
Full-thickness supraspinatus tendon tears (one of the rotator cuff muscles) and signs of shoulder joint osteoarthritis were about 10% more common in painful shoulders, but otherwise, most other MRI abnormalities were seen very frequently whether the shoulder was painful or not! This suggests that while MRI abnormalities are slightly more common in painful shoulders, many structural changes appear in both painful and non-painful shoulders–meaning these changes don’t necessarily cause pain. Furthermore, pain can improve without having to “fix” the abnormalities often seen on an MRI– even including things like rotator cuff tears! This has important implications for rehabbing your shoulder that we will discuss below.
You may be left asking: if shoulder pain isn’t necessarily related to the damage that we can see on an MRI, then what does cause it? While the things we see on MRI can be related in some cases, lots of other things contribute to pain and injury that don’t show up on scans.
Among lifters, athletes, and people with physically repetitive or demanding jobs, overuse often leads to gradually worsening aches and can increase the risk of sudden injury. Inadequate sleep and recovery can increase the risk of injury and worsen pain intensity. We also know that various other health factors can increase the risk of shoulder pain, including excess body fat, diabetes, high blood pressure, and high cholesterol — in short, our overall health has a strong impact on our risk of pain and injury in any given body area, whether our shoulders, knees, hips, or back. So, in addition to the rehab process described below, consider taking a look at our article on health priorities, and making sure those are taken care of as well.
Screening
Before you begin efforts to rehab your shoulder, it’s important to determine whether self-directed rehab is appropriate or if medical evaluation is necessary. See a professional if you experience:
- Severe, persistent pain that doesn’t improve after a few weeks
- Significant loss of strength or mobility
- Pain accompanied by numbness, tingling, or instability
- Pain caused by fall, direct impact, or sudden force to your shoulder
- Chest pain, shortness of breath, dizziness, or radiating pain down the left arm
If you do not fall into any of these categories, then the following sections on self-directed rehab for shoulder pain should guide you in the right direction.
How to Approach Shoulder Rehab
If your shoulder pain developed gradually, wasn’t caused by a sudden traumatic event, and doesn’t fall into any of the categories listed in the screening section, you’re likely safe to trial a self-directed rehab approach. While it’s understandable to want a specific diagnosis, outside of conditions like fractures, shoulder instability, adhesive capsulitis (“frozen shoulder”), cervical radiculopathy (irritated nerve in the neck), or cardiovascular-related issues, the exact diagnostic label typically doesn’t change the rehab process much.
In other words, for most common cases of shoulder pain, the rehab approach is similar, and the prognosis is generally good. As a result, the focus of rehab should be finding an appropriate starting point and progressively building strength and resilience towards those goals and the activities you value.
When beginning rehab, the key is identifying a starting point that allows you to perform daily activities and a variety of exercises that challenge the shoulder without causing significant increases in pain. How much pain is too much?
While pain during rehab can feel concerning, some discomfort is normal and even expected as your shoulder adapts to movement and loading. Instead of aiming for zero pain, think of rehab as a gradual process that introduces your shoulder to movement in a way that is tolerable, while building more capacity for activity over time. When we say “tolerable”, we mean mild to moderate levels of discomfort that do not interfere with movement and do not spike to debilitating levels during the exercise session or the 24 to 48 hours afterward.
At some point, pain might exceed your tolerance during the rehab process. Instead of stopping all activity, you can modify your training to reduce the risk of further irritation. For example, a barbell athlete experiencing an exacerbation of shoulder pain might use the following strategies:
- Swap out barbell overhead pressing for landmine pressing
- Use a pin bench press instead of a full range of motion bench press (bar pauses a few inches above the chest)
- Temporarily dial back intensity (weight on the bar) and volume (total number of sets and reps) while symptoms calm down
- Use a slower tempo such as 3s on the way down, 1s pause on the chest for the bench press to keep loading lighter – slower speeds often feel more comfortable as well
- Incorporate shoulder isolation exercises to serve as a warmup before compound lifts like the bench press or overhead press, while also building more strength and capacity for more activity in your shoulder
The rehab process should involve exercises that move and stimulate the shoulder in many different ways. This might mean trying new movements compared with the ones you’re used to. Sometimes, just doing things differently for a while and staying patient can be enough to help calm things down. We discuss this topic, as well as many other common mistakes made during the rehab process, in this article.
While exercise is the cornerstone of our approach for management of shoulder pain, many people ask about using additional treatments such as ice, massage, dry needling, injections, and medications. While these treatments can often provide temporary relief and make it easier to participate in your exercise routine, they are not necessary to facilitate your recovery. For lasting, long-term improvement, focusing on progressively loading your shoulder over time to handle the demands of your preferred activities will often yield the highest return on investment.
Case Examples
In this section we will investigate how to apply the principles from above using actual case examples from the Barbell Medicine Pain & Rehab service, with programming included for each. Names and exact details specific to each case have been slightly modified to protect the identity of the actual clients.
- Case 1: a Powerlifter with pain in the front of their shoulder
- Case 2: a CrossFit athlete & weightlifter with pain in the side of their shoulder
- Case 3: A person experiencing shoulder pain without any lifting or athletic background
Case 1: Anterior (front) shoulder pain
Jake is a 25-year-old mechanic who has been dealing with persistent pain in the front of his right shoulder for several months. He has seen his doctor twice about the issue and was diagnosed with biceps tendinitis based on the presentation of his symptoms. No imaging was done.
Prior to this issue, he was weight training 4 times per week using an upper/lower split (2 upper body sessions, 2 lower body sessions) along with training Jiu-jitsu 2-4 times per week for about 2 hours each session.
Monday consisted of heavy bench press and volume overhead press, with some bicep work. Tuesday was lower body with heavy squat and light deadlifts. Thursday was heavy overhead press and volume bench press with triceps work at the end. Saturday was lower body with volume squats and heavy deadlifts as shown below:
| Day 1 (Upper) | Day 2 (Lower) | Day 3 (Upper) | Day 4 (Lower) |
|---|---|---|---|
| Bench press: 5 sets x 1-3 reps @ RPE 8-9* | Low bar squat: 5 sets x 1-3 reps @ RPE 8-9* | Barbell overhead press: 5 sets x 1-3 reps @ RPE 8-9* | Conventional deadlift: 5 sets x 1-3 reps @ RPE 8-9* |
| Barbell overhead press: 3 sets x 6-8 reps @ RPE 7-8 | Conventional deadlift: 3 sets x 3-5 reps @ RPE 5-6 | Bench press: 3 sets x 6-8 reps @ RPE 7-8 | Low bar squat: 3 sets x 4-6 reps @ RPE 7-8 |
| Bicep curls: 3 sets x 8-12 reps @ RPE 8-9 | Triceps isolation: 3 sets x 8-12 reps @ RPE 8-9 |
*RPE = rate of perceived exertion
He had been successfully running this style of programming for over a year, seeing significant improvement in his lifts. Over time, the pain in his shoulder started to creep in after a heavy bench press session and gradually worsened for several sessions. The pain was at its worst in the bottom portion of the bench press and getting into position on low bar back squats also started to become painful.
He stopped all jiu-jitsu training, reduced load on all of his pressing movements, and tried to work back up slowly, but this only helped temporarily. The pain returned as soon as the weight on the bar increased to around 75% of his 1 rep maxes.
For the past month he has not been doing any pressing at all and just doing banded internal/external rotations based on advice from a physical therapist on YouTube. He has been using a safety bar for his squatting work since the low bar position is quite painful to get into currently.
His goals are:
- Get back to previous levels of performance (and beyond) on the bench press, overhead press, and low bar squat
- Be able to attend Jiu-jitsu classes without aggravating his shoulder
Here are the initial modifications that were made to his programming to help reduce pain with aggravating movements and establish an entry point:
| Day 1 (Upper) | Day 2 (Lower) | Day 3 (Upper) | Day 4 (Lower) |
|---|---|---|---|
| Sidelying External Rotation: TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 / side | Safety Bar Squat: 3 sets x 4-6 reps @ RPE 7-8 | Sidelying External Rotation: TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 / side | Conventional deadlift: 5 sets x 1-3 reps @ RPE 8-9 |
| Dumbbell Preacher Curl: TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 | Conventional deadlift: 3 sets x 3-5 reps @ RPE 5-6 | Dumbbell Preacher Curl: TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 | High Bar Squat: 3 sets x 4-6 reps @ RPE 7-8 |
| Low Pin Bench Press: TEMPO: 3.1.0 = 3s on the way down, 1s pause in the bottom 6 reps @ RPE 5 6 reps @ RPE 6 6 reps @ RPE 7 NOTE: Bar should pause on the pins just above point of discomfort | Barbell Overhead Press TEMPO: 2.0.2 = 2s on the way up, 2s on the way down 8 reps @ RPE 5 8 reps @ RPE 6 8 reps @ RPE 7 | ||
| Regular Bench Press TEMPO: 3.1.0 = 3s on the way down, 1s pause on the chest 1-2 sets x 6 reps @ 15-20% load drop from top set of pin bench (RPE CAP: 7) | Lat Pulldown TEMPO: Normal 3 sets x 8-12 reps @ RPE 8 | ||
| Landmine Meadow’s Row TEMPO: Normal 3 sets x 8-12 reps @ RPE 8 | Floor Press TEMPO: 3.1.0 = 3s on the way down, 1s pause in the bottom 10 reps @ RPE 5 10 reps @ RPE 6 10 reps @ RPE 7 | ||
| Standing Landmine Press TEMPO: 2.0.2 = 2s on the way up, 2s on the way down 12 reps @ RPE 6 12 reps @ RPE 7 12 reps @ RPE 8 | Triceps isolation: 3 sets x 8-12 reps @ RPE 8-9 |
Both of his upper body days begin with a sidelying external rotation and dumbbell preacher curl with the intention to serve as a warmup and to build more capacity in his shoulder and irritated biceps tendon prior to his compound pressing movements.
On Day 1, the heavy bench press was substituted for a low pin bench press where the pins are set just above the point where his symptoms begin to drastically increase. The slower tempo and slightly higher rep ranges should keep loading lighter and help the bench press feel more comfortable. He was instructed to take smaller jumps between sets to better assess his load tolerance, accumulate more volume, and to achieve more of a warmup effect leading into his top set. Lastly, he was instructed to anchor RPE 10 to his tolerance level for symptoms, not true performance failure, to help with keeping loading more conservative especially in the first few weeks.
After the pin bench press, 1-2 sets of full range of motion bench press were included to get reacclimated to the bottom position starting with lighter loads.
The landmine press was substituted in place of his volume focused barbell overhead press to achieve more pressing volume while making the range of motion more tolerable. This substitution also serves to reduce overall loading through the shoulder with the slower tempo, higher rep range, and the nature of the exercise (less loadable). The landmine Meadow’s row was included as well to make the transition to upper back work easier from a time perspective.
On Day 2, the safety bar squat was subbed in place of the low bar squat temporarily to allow for efficient leg training without irritating his shoulder. Same idea on Day 4 with the switch to high bar squats. Deadlift work remained as is.
For Day 3, the same concepts from Day 1 all apply here. Higher rep tempo work was included on the barbell overhead press, and the floor press was subbed in for regular bench press to limit the range of motion.
Every 2 weeks, the rep schemes on the pin bench press, barbell overhead press, and floor press were lowered by 1-2 reps. Load caps of no more than 10lb jumps week to week were put in place on his compound lifts. Jake ran this programming for ~6 weeks, gradually progressing the load on each of his lifts.
Here is Jake’s programming for phase 2:
| Day 1 (Upper) | Day 2 (Lower) | Day 3 (Upper) | Day 4 (Lower) |
|---|---|---|---|
| Sidelying External Rotation: TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 / side | Low Cable Triceps Kickback 2 sets x 12 reps @ RPE 8 / side | Sidelying External Rotation: TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 / side | Conventional deadlift: 5 sets x 1-3 reps @ RPE 8-9 |
| Dumbbell Curl TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 | Low Bar Squat: 3 sets x 4-6 reps @ RPE 7-8 | Dumbbell Curl TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 | High Bar Squat: 3 sets x 4-6 reps @ RPE 7-8 |
| Slingshot Bench Press TEMPO: Self-selected 1 rep @ RPE 7 2 sets x 3 reps @ 5-8% load drop | Conventional deadlift: 3 sets x 3-5 reps @ RPE 5-6 | Barbell Overhead Press TEMPO: Self-selected 4 reps @ RPE 5 4 reps @ RPE 6 4 reps @ RPE 7 | |
| Regular Bench Press TEMPO: Self-selected 2 sets x 5 reps @ 15-20% load drop from top single on slingshot bench press | Lat Pulldown TEMPO: Normal 3 sets x 8-12 reps @ RPE 8 | ||
| Barbell Row TEMPO: Normal 3 sets x 6-10 reps @ RPE 8 | Bench Press TEMPO: 3.1.0 = 3s on the way down, 1s pause in the bottom 6 reps @ RPE 5 6 reps @ RPE 6 6 reps @ RPE 7 | ||
| Seated Barbell Overhead Press TEMPO: Self-selected 8 reps @ RPE 6 8 reps @ RPE 7 8 reps @ RPE 8 | Triceps isolation: 3 sets x 8-12 reps @ RPE 8-9 |
For Day 1, the slingshot bench press was substituted in for the pin bench press. Jake had access to the red slingshot in particular, which offloads the bottom portion of the range of motion on bench press and makes it easier to accelerate off of the chest with less demand on the shoulder. He used this for his ‘heavier’ bench press work, and regular full range of motion bench press was included in the drop down sets to accumulate more training volume and exposure to the bottom position.
The sidelying external rotation exercise remained and the dumbbell preacher curl was progressed to a regular dumbbell curl. The landmine press was substituted out for seated barbell overhead press to increase specificity to his goal of increasing his 1 rep max on the overhead press. Barbell rows were substituted in for landmine rows more for personal preference and desire for some exercise variety.
On Day 2, Jake started the session using a cable triceps kickback with an emphasis on keeping his elbow high and driving the cable as far back behind his torso as possible. This movement is training shoulder extension (moving the arm behind the body), which is important for being able to comfortably get into position on a low bar squat. The intention with this exercise is to serve as a warmup prior to getting under the bar for the re-introduction of low bar squats into his routine.
On Day 3, the standing barbell overhead press was brought down to sets of 4 and the floor press was substituted out for tempo bench press to increase specificity to his goals. The tempo for each of his pressing movements were changed to ‘self-selected’, meaning he could go as fast as he felt comfortable with. The load caps of no more than 10lb jumps week to week remained in place on his compound lifts. Jake ran this setup for another ~6 weeks, gradually progressing load.
Here is the final phase of Jake’s programming:
| Day 1 (Upper) | Day 2 (Lower) | Day 3 (Upper) | Day 4 (Lower) |
|---|---|---|---|
| Regular Bench Press TEMPO: Normal 3 reps @ RPE 6 3 sets x 5 reps @ 10-15% load drop | Low Bar Squat: 3 reps @ RPE 6 3 sets x 5 reps @ 10-15% load drop | Barbell Overhead Press TEMPO: Normal 3 reps @ RPE 6 3 sets x 5 reps @ 10-15% load drop | Conventional deadlift: 5 sets x 1-3 reps @ RPE 8-9 |
| Barbell Row TEMPO: Normal 3 sets x 6-10 reps @ RPE 8 | Conventional deadlift: 3 sets x 3-5 reps @ RPE 5-6 | Pull-ups 3 sets x RPE 8 | Low Bar Squat: 3 sets x 4-6 reps @ RPE 7-8 |
| Barbell Overhead Press TEMPO: Normal 3 sets x 4-6 reps @ RPE 7 | Slingshot Bench Press TEMPO: Normal 3 sets x 4-6 reps @ RPE 7 | ||
| Incline Dumbbell Curl TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 | Tricep isolation: 3 sets x 8-12 reps @ RPE 8-9 | ||
| Incline Dumbbell Curl TEMPO: Slow and controlled 2 sets x 12 reps @ RPE 8 |
In this phase the emphasis was on increasing specificity and returning Jake to his ‘normal’ routine. On Days 1, 2 & 3, the sidelying external rotation and cable triceps kickback exercises were removed, and Jake was instructed to incorporate those only as needed. The dumbbell curls were progressed to incline dumbbell curls to help with continuing to build more capacity and loading tolerance through his biceps tendon, but they were included at the end of Days 1 & 3 as opposed to the beginning. At this phase Jake was feeling better, and his shoulder pain was much less, and given his limited time to train each day, these changes were implemented.
His bench press on Day 1 was switched to a top set of 3 reps starting at RPE 6 in week 1, which progressed up to RPE 8.5 – 9 over the course of 6 weeks. The same approach was used on his low bar squat on Day 2, and barbell overhead press on Day 3. The seated barbell overhead press was progressed to another day of standing barbell overhead press to increase specificity.
On day 3, the slingshot bench was moved here in place of the tempo bench press to keep some exposure to heavier loading while still reducing the demand of the shoulder in the bottom position to help with overall load management. Pull-ups were subbed in place of lat pulldowns based on personal preference and desire to change up the exercise selection.
After running this setup for 6 weeks and being able to hit some new 3 rep maxes on his main lifts, Jake was ready to return to his normal programming while adopting the principles he learned from his rehab.
Case 2: Lateral (side) / “deep” shoulder pain
Jessica is a 32-year-old fitness coach who loves all things training. She has competed in CrossFit competitions, powerlifting meets, half-marathons, and weightlifting meet as well. Around 3 months ago, she started feeling a deep ache in her right shoulder after doing a CrossFit workout that involved lots of overhead barbell snatches and handstand walks. After several nights of poor sleep due to the pain, she went to an Orthopedic doctor who performed various tests. Their conclusion was that she was dealing with shoulder impingement and a possible labral tear. From there, she underwent an MRI of her shoulder, which confirmed a labral tear along with ‘degenerative’ changes along her acromioclavicular joint. She was recommended to trial physical therapy before being considered for surgery.
Prior to this issue, she was weight training 3 times per week with 2 days of general strength training focus and one day of a CrossFit/Olympic weightlifting style of training.
Day 1 was her heavy bench press day with upper body accessory work. Day 2 was her Olympic lifting day with the barbell snatch and clean & jerk along with a CrossFit style METCON that varied each week. Day 3 was her volume focused bench press day with upper body accessory work.
| Day 1 (Upper) | Day 2 (CrossFit/Oly lifting) | Day 3 (Upper) |
|---|---|---|
| Bench press: Top set of 1-3 reps @ RPE 7-9 3 sets x 3-5 reps @ 12-18% load drop from top set | Barbell Snatch 4-6 sets x 1-3 reps @ RPE 6-7 | Bench Press 3 sets x 4-6 reps @ RPE 7-8 |
| Incline Dumbbell Bench Press 3 sets x 8-12 reps @ RPE 8 | Clean & Jerk 4-6 sets x 1-3 reps @ RPE 6-7 | Chest Press Machine 4 sets x 6-10 reps @ RPE 8 |
| Lat Pulldown 3 sets x 8-12 reps @ RPE 8 | MetCon of the day Example workout: 8 Rounds @ sustained pace 250m Row 12 kettlebell swings @ 35% of Bodyweight 50m kettlebell farmer’s carry 8 Push-Up | Seated Cable Row 3 sets x 8-12 reps @ RPE 8 |
Her shoulder hurts the most when trying to do any type of overhead work such as the barbell snatch, overhead press, and clean & jerk. When her shoulder is really flared up, even lifting her arm overhead can be painful. The bench press hurts the most coming off the chest, but doesn’t really bother her until she reaches about 85% of her max.
Her goals are to:
- Have her shoulder be pain-free
- Get back to previous levels of performance (and beyond) on the bench press
- Be able to perform CrossFit workouts and Olympic lifts (snatch + clean & jerk) without aggravating her shoulder
Here are the initial modifications that were made to her programming to help reduce pain with aggravating movements and establish an entry point:
| Day 1 (Upper) | Day 2 (Crossfit/Oly lifting) | Day 3 (Upper) |
|---|---|---|
| Low Pin Bench press: TEMPO: 3.1.0 = 3s on the way down, 1s pause on the chest Top set of 1-3 reps @ RPE 6-8 3 sets x 3-5 reps @ 12-18% load drop from top set | Prone Y’s & Serratus Wall Slides 2-3 sets x 8-12 reps @ RPE 7-8 | Floor Press TEMPO: 3.1.0 = 3s on the way down, 1s pause on the chest 3 sets x 4-6 reps @ RPE 7-8 |
| Push-up Plus TEMPO: Slow and controlled 3 sets to RPE 8 | Muscle Snatch 3 sets x 4-6 reps @ RPE 6-7 | Single Arm Dumbbell Bench Press with Serratus Punch 3 sets x 6-10 reps @ RPE 8 / side |
| Lat Pulldown 3 sets x 8-12 reps @ RPE 8 | Muscle Clean 3 sets x 4-6 reps @ RPE 6-7 | Seated Cable Row 3 sets x 8-12 reps @ RPE 8 |
| Low Intensity Steady State Cardio 20 minutes at RPE 4-5 / Zone 2 / talking pace with modality of choice (exclude cardio machines that involve the shoulder such as rowing, ski erg, etc.) | Single Arm Bottoms Up Kettlebell Press TEMPO: 2.0.2 = 2s on the way up, 2s on the way down 2 sets x 8-12 reps @ RPE 8 / side | Low Intensity Steady State Cardio 20 minutes at RPE 4-5 / Zone 2 / talking pace with modality of choice (exclude cardio machines that involve the shoulder such as rowing, ski erg, etc.) |
| High Intensity Interval Training on Assault Bike 30s at RPE 7-8 / Zone 4/ difficult pace to maintain 60-90s at RPE 4-5 / Zone 2/ talking pace Repeat for 8 rounds Note: Focus on generating most of the power with your legs, arms are just along for the ride |
On Day 1, the bench press programming was modified to by subbing in a low pin bench press, using a slower tempo, and a slight reduction in RPE since she really didn’t have any issues with her shoulder unless the barbell was coming off of the chest with ~85% or more of her max. She was instructed to have the bar pause on the pins just above that point of discomfort.
In addition, the incline dumbbell bench press was subbed out for a push-up plus, which is simply a regular push-up with an extra emphasis on pushing the shoulder blades apart (scapular protraction) at the top. The reaching motion through the shoulder blades is performed by a muscle called the serratus anterior and is important for stabilization and overall function of the shoulder. This variation of the push-up will also help to reduce overall loading through the shoulder relative to the incline dumbbell bench press and should be more tolerable in the beginning phases of the rehab process.
The lat pulldown was left in as is and low intensity steady state (LISS) cardio was included at the end of the session to help with maintaining/improving Jessica’s cardiovascular base while working through her rehab.
On Day 2, the session begins with prone Y’s and serratus wall slides. These exercises are intended to warm up the muscles responsible for moving the shoulder blades and arm overhead prior to starting her Olympic lifts. The snatch and clean & jerk were modified to muscle snatches and cleans for this phase. These variations involve lifting the barbell from the floor to an overhead position without the explosive drop underneath the bar and are typically much more tolerable for the shoulder given the slower speed and lighter loading.
Afterward, a single arm bottoms up kettlebell press was included to accumulate more overhead pressing volume with much lighter loads and to increase overall confidence in stabilizing the shoulder in overhead positions. Lastly, the METCON was replaced with high intensity interval training (HIIT) using an assault bike to continue building her anaerobic cardiovascular endurance. She was instructed to do the majority of work with her legs and just bring her arms ‘along for the ride’ to reduce the risk of aggravating her shoulder.
On Day 3, the bench press work substituted out for a barbell floor press to reduce the range of motion and to bring down the overall intensity (weight on the bar/% of 1 rep max) through the use of a slower tempo and slightly lower RPE prescriptions since her shoulder was sensitive to loads approaching around 85% of her max. The chest press machine was subbed out for a single arm dumbbell bench press with a serratus punch, which involves lifting the shoulder blade off the bench at the top. The intention here was similar to the switch to the push-up plus on Day 1: reduce overall loading and build the strength/capacity of the muscles surrounding the shoulder blades. Cable rows remained as programmed and LISS cardio was included on this day as well.
Jessica performed this programming for ~4 weeks before moving on to the next phase outlined below:
| Day 1 (Upper) | Day 2 (CrossFit/Oly lifting) | Day 3 (Upper) |
|---|---|---|
| Bench press: TEMPO: 3.1.0 = 3s on the way down, 1s pause on the chest Top set of 1-3 reps @ RPE 6-8 3 sets x 3-5 reps @ 12-18% load drop from top set | Prone Y’s & Serratus Wall Slides 2-3 sets x 8-12 reps @ RPE 7-8 | Bench Press TEMPO: 3.1.0 = 3s on the way down, 1s pause on the chest 3 sets x 4-6 reps @ RPE 7-8 |
| Dips with reach at top TEMPO: Slow and controlled 3 sets to RPE 8 with bodyweight (cap at 15 reps) | Power Snatch 4 sets x 3-5 reps @ RPE 6-7 | Dumbbell Bench Press 3 sets x 6-10 reps @ RPE 8 |
| Lat Pulldown 3 sets x 8-12 reps @ RPE 8 | Power Clean 4 sets x 3-5 reps @ RPE 6-7 | Seated Cable Row 3 sets x 8-12 reps @ RPE 8 |
| Low Intensity Steady State Cardio 30 minutes at RPE 4-5 / Zone 2 / talking pace with modality of choice (exclude cardio machines that involve the shoulder such as rowing, ski erg, etc.) | Single Arm Landmine Press TEMPO: Normal 2 sets x 8-12 reps @ RPE 8 / side | Low Intensity Steady State Cardio 30 minutes at RPE 4-5 / Zone 2 / talking pace with modality of choice (exclude cardio machines that involve the shoulder such as rowing, ski erg, etc.) |
| METCON of choice with lower body emphasis |
In this phase the low pin press and floor press were subbed in for regular bench press, but the slower tempo’s remained to help with managing overall load.
The push-up plus was progressed to strict dips with a reach at the top (to target the serratus), the bottoms up kettlebell press was replaced with a single arm landmine press, and the single arm dumbbell bench press was switched to regular dumbbell bench press all to further increase the strength and capacity of her shoulder.
The muscle snatch and clean were progressed to power variations to help with re-introducing the speed component of those movements.
LISS cardio progressed to 30 minutes on Days 1 & 2, and the HIIT cardio was subbed out for Jessica’s METCON of choice with an emphasis on lower body movements, which meant no handstand walks, overhead work, explosive med ball throws, etc.
Jessica ran this block of programming for another ~4 weeks before progressing to the final phase:
| Day 1 (Upper) | Day 2 (CrossFit/Oly lifting) | Day 3 (Upper) |
|---|---|---|
| Bench press: TEMPO: Normal Top set of 1-3 reps @ RPE 6-8 3 sets x 3-5 reps @ 12-18% load drop from top set | Prone Y’s & Serratus Wall Slides 2-3 sets x 8-12 reps @ RPE 7-8 | Bench Press TEMPO: 3.1.0 = 3s on the way down, 1s pause on the chest 3 sets x 4-6 reps @ RPE 7-8 |
| Feet Up Bench Press TEMPO: Normal 2 sets x 6-8 reps @ RPE 8 | Snatch 5 sets x 1-3 reps @ RPE 6-7 | Dumbbell Bench Press 3 sets x 6-10 reps @ RPE 8 |
| Lat Pulldown 3 sets x 8-12 reps @ RPE 8 | Clean & Jerk 5 sets x 1-3 reps @ RPE 6-7 | Seated Cable Row 3 sets x 8-12 reps @ RPE 8 |
| Low Intensity Steady State Cardio 30 minutes at RPE 4-5 / Zone 2 / talking pace with modality of choice (exclude cardio machines that involve the shoulder such as rowing, ski erg, etc.) | Push Press TEMPO: Normal 6 reps @ RPE 5 6 reps @ RPE 6 6 reps @ RPE 7 | Low Intensity Steady State Cardio 30 minutes at RPE 4-5 / Zone 2 / talking pace with modality of choice (exclude cardio machines that involve the shoulder such as rowing, ski erg, etc.) |
| METCON of choice |
In this final phase the emphasis was on increasing specificity and returning Jessica to her normal routine. On Day 1 the bench press returned to normal tempo using the top set and backdown set approach. Dips were subbed out for feet up bench press to increase specificity toward her bench press goals.
On Day 2 the normal snatch and clean & jerk were re-introduced into her routine along with a barbell push press in place of the landmine press to help with building more capacity in the overhead position. She was encouraged to engage in her METCON of choice while being cognizant of her shoulder. Day 3 remained as is.
At the end of this block Jessica was able to hit her previous bench press max with zero pain and her confidence with the Olympic lifts and CrossFit workouts was restored.
Case 3: Posterior (back) shoulder pain
Anthony is a 63-year-old retired dentist with persistent right shoulder pain for the past several weeks after completing a carpentry project. The project took approximately 3 days to complete with 4-6 hours of work each day. He started to notice a dull, posterior shoulder pain on his right-side during day 3 while installing cabinets in the kitchen. He was hoping the pain would resolve after a few days of rest, but unfortunately it worsened. Now he was struggling to put on a jacket, reach overhead into a cabinet, and put on his seatbelt in the car.
Anthony decided to schedule an appointment with an orthopedic doctor who recommended him for physical therapy to address his shoulder limitations.
Anthony had no prior history of resistance training or exercise experience outside of a brief stint of weight training for high school football many decades ago.
His goals are:
- Resolve his shoulder pain
- Be able to play with his grandkids
- Be able to do carpentry, gardening, painting, and landscaping projects around the house
Here is Anthony’s programming:
| Day 1 | Day 2 | Day 3 |
|---|---|---|
| Standing Scaption with a Resistance Band 3 sets x 10-15 reps @ RPE 8 | Prone T with Dumbbell 3 sets x 10-15 reps @ RPE 8 / side | Serratus Wall Slides 3 sets x 8-12 reps |
| Standing Cable External Rotation 3 sets x 10-15 reps @ RPE 8 / side | Sidelying External Rotation 3 sets x 10-15 reps @ RPE 8 / side | Prone Y with Dumbbell 3 sets x 10-15 reps @ RPE 8 |
| Single Arm Cable Pulldown 3 sets x 8-12 reps @ RPE 8 | Seated Cable Row 3 sets x 8-12 reps @ RPE 8 | Lat pulldown 3 sets x 8-12 reps @ RPE 8 |
| Standing Landmine Press TEMPO: 2.0.2 = 2s on the way up, 2s on the way down 3 sets x 8-12 reps @ RPE 8 | Bench press TEMPO: 3.1.0 = 3s on the way down, 1s pause on the chest 5 reps @ RPE 5 5 reps @ RPE 6 5 reps @ RPE 7 | Seated Dumbbell Overhead Press TEMPO: 2.0.2 = 2s on the way up, 2s on the way down 3 sets x 8-12 reps @ RPE 8 |
| Wall Pushup TEMPO: Slow and controlled 3 sets to RPE 8 (Cap at 15 reps | Rope Cable Face Pull 3 sets x 8-15 reps @ RPE 8 | Cable Lateral Raise 3 sets x 8-15 reps @ RPE 8 |
Day 1 begins with standing scaption using a resistance band and a cable external rotation to serve as a warmup for Anthony’ shoulders. Since Anthony has very little history with exercise outside of his carpentry projects, these exercises should also provide a good training stimulus for building strength as well. Up next is a single arm cable pulldown to target the back musculature in a controlled manner. Anthony was also able to self-select the angle of the cable based on the comfort level of his shoulder.
After all of the shoulder isolation and pulling exercises, Anthony was easily able to work up to his top set on the standing landmine press. The landmine press is a great overhead pressing movement because it allows the range of motion to be self-selected based on comfort. Day 1 concluded with some wall pushups for additional pressing volume.
Day 2 began with a Prone T using a dumbbell and sidelying external rotation, again to help with warming up the muscles around Anthony’s shoulder and shoulder blade. The seated cable row was introduced next to target the back musculature before moving on to the barbell bench press. The parameters for the bench press were selected to help Anthony learn how to safely and efficiently perform the movement. A slow tempo was used to help with honing technique and using lighter weights in the beginning stages. Ascending sets of 5 were used to help with breaking up the sets into manageable chunks so that fatigue doesn’t become a big factor during the later reps. The workout ended with a cable rope face pull to target the muscles along the backside of his shoulders.
Day 3 followed a similar structure to Days 1 & 2 with the shoulder warmup work in the beginning, a back exercise, pressing exercise, and ended with a shoulder isolation exercise.
Anthony ran this programming for ~ 2 months with some slight modifications week to week to make some exercises more challenging as needed. He found significant relief from his shoulder pain and felt much stronger and confident in using his shoulder in daily activities. He also discovered a newfound enjoyment for resistance training and continued on with an exercise routine after completion of his rehab.
As you can see from the case examples, rehab for shoulder pain will look slightly different based on the individual, their goals, equipment availability, work schedule, and several other factors. Hopefully these cases have provided more insight on how to navigate shoulder pain while working towards the activities you want to get back to. If you are still finding this process overwhelming or you are interested in individualized help, the Barbell Medicine Pain & Rehab team is available and happy to help with consultations and coaching.
