I’ve done my share of bench presses, mostly back in my bodybuilder years before I got involved in Olympic weightlifting. Back then (well before I was a physical therapist) if someone in the gym had shoulder pain with bench press, none of us knew what it was, and almost nobody thought to see a doctor or physical therapist about it. The general advice among lifters was to change the grip, lighten the weights, do higher reps, change the arc of motion, do dumbbells, do something, do anything different, all with greater or lesser amount of success and eventually something usually did “work.” That’s the thing with tendinopathy. It is usually self limiting, which means even if you do nothing it eventually gets better. The result is something is bound to be correlated and thus credited with the resolution of symptoms. “Post hoc ergo propter hoc” is the proper Latin term for the phenomenon of why people get all kinds of genuine well meaning and heart felt advice as to what ‘works’ to cure tendinopathy.
Since I don’t want to type big words over and over here’s my abbreviations in one place:
- CP: coracoid process
- SHB: short head of biceps brachii
- LHB: long head of biceps brachii
- CB: coracobrachialis
- PM: pectoralis minor
- RTC: rotator cuff
- SFR: supinated front raise
I go into it in nauseating detail in my most recent and what I think is my best blog ever: Coracoidopathy, the Missing Link in Shoulder Pain. However, I also think that blog might be an overkill of information and terminology for someone who just has some anterior shoulder pain when bench pressing. Plus, I had some things to say regarding bench press in particular that felt a bit out of place in the Missing Link paper. So I did another video (scroll near the bottom) in relation to coracoidopathy and bench press in more of a, “If it hurts here, do this” style. So if you have faith (thanks) just push play, if you need more convincing and some detail (you should) read below, and if you need a lot of convincing definitely click on my best blog ever above.
Regarding the association between coracoidopathy and bench press, for me, it began when I was talking about coracoidopathy and SFRs and how with, SFRs the third/heavier set almost always feels better than the first/lighter set. One of my patients was listening, and mentioned his shoulder hurt with bench press and asked what if you did the SFRs right before you benched, would the benching feel better? I thought, “that’s a great question, let’s find out right now.” I tested his shoulder, and decided it was isolated coracoidopathy he had, and then proceeded by having him do SFRs for 3 sets of 15 with with 5, 8 and 10 pounds. Immediately afterwards he did bench press, which was painless. In the months that followed several other friends (or friends of friends) with shoulder pain during bench presses reported similar (complete or much improved) acute relief of symptoms immediately after doing SFRs and with a full resolution of symptoms with continued use of the exercise.
Then I got a patient who said he originally injured doing snatches in CrossFit, but his shoulder was bothering him a lot when he bench pressed. I diagnosed him with isolated coracoidopathy but when I tried the above protocol (with 5, 8, 10, 12, 15 lb, extra sets because 10 lb was too light) his typical bench press pain of 7/10 was reduced to 5/10. Now although this was good, it wasn’t good enough, so I made some changes to the program, in what I illustrate below as “Strategy-2”, which by his second visit decreased bench press pain to 1-2/10. By his 4th visit, he said he still had some soreness in CrossFit but was able to do everything (including snatches). By his 11th visit, 28 days later (doing SFRs daily between treatments), he worked up to doing 15-20-25 lb on SFRs for his 3 sets. At this point he reported he was 100% recovered, with no pain during any exercise or daily activities, including both bench pressing and CrossFit exercises.
Only after all the above, as I was finalizing my write up on coracoidopathy did I come across the following study on “bench-presser’s shoulder”, which I think was in fact coracoidopathy, or if you prefer Karim 2005’s name for the condition “enthesitis of biceps brachii short head and coracobrachialis at the coracoid process” which I think is the true first with regards to the description of the diagnosis. Still I thought Bhatia’s paper, is important in that they confirmed the association between anterior shoulder pain and bench press coming from the coracoid process. Pain was eliminated with ‘almost’ exactly the same treatment, though slightly different explanation as Karim.
From Bhatia’s Study
The “bench-presser’s shoulder”: an overuse insertional tendinopathy of the pectoralis minor muscle. Bhatia DN, de Beer JF, van Rooyen KS, Lam F, du Toit DF. Br J Sports Med. 2007 Aug;41(8):e11. Epub 2006 Nov 30. [FREE FULL TEXT]
Tendinopathies of the rotator cuff muscles, biceps tendon and pectoralis major muscle are common causes of shoulder pain in athletes. Overuse insertional tendinopathy of pectoralis minor is a previously undescribed cause of shoulder pain in weightlifters/sportsmen.
To describe the clinical features, diagnostic tests and results of an overuse insertional tendinopathy of the pectoralis minor muscle. To also present a new technique of ultrasonographic evaluation and injection of the pectoralis minor muscle/tendon based on use of standard anatomical landmarks (subscapularis, coracoid process and axillary artery) as stepwise reference points for ultrasonographic orientation.
Between 2005 and 2006, seven sportsmen presenting with this condition were diagnosed and treated at the Cape Shoulder Institute, Cape Town, South Africa.
In five patients, the initiating and aggravating factor was performance of the bench-press exercise (hence the term “bench-presser’s shoulder”). Medial juxta-coracoid tenderness, a painful active-contraction test and bench-press manoeuvre, and decrease in pain after ultrasound-guided injection of a local anaesthetic agent into the enthesis, in the absence of any other clinically/radiologically apparent pathology, were diagnostic of pectoralis minor insertional tendinopathy. All seven patients were successfully treated with a single ultrasound-guided injection of a corticosteroid into the enthesis of pectoralis minor followed by a period of rest and stretching exercises.
This study describes the clinical features and management of pectoralis minor insertional tendinopathy, secondary to the bench-press type of weightlifting. A new pain site-based classification of shoulder pathology in weightlifters is suggested.
My thoughts on the study
As for Bhatia, I think he’s more or less right that there is a definite association between coracoidopathy and the bench press exercise. Of the 60-70 ‘patients’ I have treated with some degree of coracoidopathy only one was referred from a doctor with pain related to bench press. However, of all the people I’ve known reporting pain with bench press (6 thus far since becoming aware of coracoidopathy as a diagnosis) have had isolated coracoidopathy, which responded favorably to my giving them SFRs as an exercise. So if you have anterior shoulder pain, particularly in the front of your shoulder with bench press, I think there’s a good chance that it is coracoidopathy.
While I think Bhatia is correct about the association between bench press and coracoidopathy, I think it’s likely his group is incorrect when they implicate the PM as the primary irritated tendon. I’m also skeptical that their patients were tender with palpation over just the medial aspect of their coracoid process. This is because the coracoid process is quite small, such that everyone I have treated has been either tender there or not. Localization to a particular side maybe not impossible, but I think it is improbable to distinguish. I also don’t think the manual tests they used to implicate the PM were precise enough to effectively isolate and the implicate the PM tendon. Rather, I think that Karim 2005 nailed the diagnosis more precisely, even if they hid it behind an awkward name. My own experience combining tenderness with palpation of the coracoid process with pain and/or weakness with resistance through both the SHB and CB (with a Speed’s test) as well as a good treatment effect with SFRs (which is basically making the Speed’s test into an exercise) being the reasons why.
Bhatia’s treatment, like Karim’s was an anesthetic and corticosteroid injection to the medial and coracoid process/PM tendon, which fully resolved symptoms. However, in my main coracobrachialis paper I go into detail (with citations) as to why I think cortisone for tendinopathy is a bad idea. The main reason is that cortisone makes tendons weaker, with several studies indicating pain may be reduced in the short term but on average patients are worse off in the long term. Besides, cortisone requires a doctor’s appointment and copay, while if you have dumbbells or a gym membership already, SFRs are free!
My observations regarding coracoidopathy and the bench press exercise.
Their coracoidopathy usually isn’t that bad. Not bad enough for most people to seek treatment. More than often, they just notice their shoulder hurts, but they usually just end up living with it because it’s not interfering with their daily lives much at all, it just interfered with their workouts, particularly bench press.
To go along with their tendinopathy being more minor, while they are tender over their coracoid process their Speed’s test was still relatively strong and only a little painful in comparison to the average person with coracoidopathy. However, you can often tell a difference in relation to their other/good side.
They tend to be more fit than average. Obviously they worked out doing bench press among other exercises so they don’t have to add a lot of exercise to their program to increase general upper body and/or shoulder stabilization strength. It is very likely that just adding the SFR to the routine is enough to cure the condition. If, on the contrary, there were muscle imbalances or other shoulder problems, additional exercises from my more comprehensive treatment program might be necessary.
My two treatment strategies
This leaves me with two strategies, for which I am not yet sure which is best.
Strategy-1: Do SFRs 3 sets of 15 reps (easy-medium-hard) every day, and right before you do bench press. I’m aware of the fact that if people are going to bench press they are almost always going to do it first (I always did). That way your SHB and CB tendons/muscles will be warmed up before benching. It might also be a good idea to keep the reps higher (maybe 10-15s) on bench press itself for a while, until pain resolves. Doing SFRs only on bench days (rather than my preferred frequency of daily) will probably still work, but I find (and science agrees) that tendons heal better with daily treatment. Once cured, or nearly cured, I think it’s OK to drop the frequency back to just bench days. When fully cured I’d probably stop doing them, as I think of SFRs as a rehab exercise rather than for general fitness.
Strategy-2: Strategy-2 is for worse case scenario, when a shoulder doesn’t react as well as I had hoped to with strategy-1. The plan would be to begin the workout with back exercises to further warm up the shoulder (as per my basic workout) then perform the SFRs mid workout, followed by bench press right after and towards the end of the workout. Although it’s conventional for lifters to train bench press first in a workout, some lifters have relatively overdeveloped chest, anterior deltoids, and shoulder internal rotation strength (compared to back, posterior delts, and shoulder external rotation strength). So, beginning with back might have several potential benefits such as letting you train the back harder, perhaps better correcting muscle imbalances that could have predisposed one to coracoidopathy in the first place. It would also better warm up the shoulders making SFRs and bench press both feel better when you get there, thus less limited by pain. Lastly, training chest later in the workout, would have you a little more fatigued when you got there, so you would be less likely to use weights that might further injury.
Other thoughts: Somewhere on chest day (before or after bench) it might be worthwhile to do dumbbell pullovers. I say this because I think it is a great exercise for both strength and stretch. I see a lot of shoulder patients, and older people in general who can’t get their arms all the way overhead, and pullovers are one of my favorite ways to stretch that. Also, if Bhatia is correct that the PM is a/or the source of coracoid process pain, then I think pullovers would be the best way to stretch, tension and strengthen the pec minor. The fact that all my people thus far respond so well to the SFR is the main reason think it isn’t the PM most of the time, however there is no reason it couldn’t be the pectoralis minor some of the time.
As for where coracoidopathy hurts, and a SFR technique, it’s a lot easier to show than to tell, so here’s a demo by yours truly.
I should add that while I think coracoidopathy is often the cause of shoulder pain with bench press, it is obviously not the only cause, and my own data confirms that coracoidopathy very frequently co-occurs with RTC tendinopathy and other shoulder issues. As such, if one’s bench press shoulder pain isn’t coracoidopathy the SFRs aren’t going to work. If shoulder pain is more severe and more complicated than isolated coracoidopathy, and if the shoulder does not respond positively to the addition of the SFRs it might be worth seeing a doctor or physical therapist. If coracoidopathy (tendinopathy of the coracoid process) is part of the problem you’re probably going to have to educate your local health care provider about it because it’s generally not something they have heard about.
As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.
Chad Reilly, Physical Therapist