Elbow and Shoulder Pain During Pressing/Pushing – Importance of Load Ordering on Pressing Mechanics

Last week we discussed the importance of load ordering on squat mechanics. Had some great response to it so this week I want to discuss the analog to this in the upper extremity – pressing/pushing movements.

Here’s the problem:
Are there any movements that have destroyed the human upper extremity more than the bench press, push-up, and dip? Seriously think about how many guys at the gym throw up a ton of weight on bench only to sneak away and rub their anterior shoulder in the corner. Or insidious elbow pain that kicks in after your set of dips. Nasty levels of performance and skill transfer to athletic and everyday movements – such moving boxes or blocking a defensive lineman – require proper load ordering of the joints and tissues.

There are two main foci when looking at pushing mechanics: load ordering (essentially motor control) and mobility (particularly of the shoulder into extension and internal rotation – read this post on how to improve shoulder position for pressing). Both are pertinent but in sticking with our theme from last week, let’s look at load ordering as motor control is always the top priority when improving human movement. As discussed, the joints and tissues loaded first in a movement are the joints and tissues loaded most. Specifically, erroneously loading the elbow first during pressing activities (think push-ups, bench press, or moving/lifting things in the home). Just as with loading the knee first in a squat, loading the elbow first in presses (including dips – a huge elbow destroyer!) subjects the elbow and triceps complex to crushing forces that cannot be avoided once under tremendous external load. And good luck generating triceps force with such over-tension in the elbow/triceps complex.

Proximal stability of the shoulder drives distal (elbow) mobility. Without properly loading the shoulder, which is the powerhouse of the upper extremity (analogous to the hip), the elbow and triceps are unable to do their job which is to straighten the arm. The result: crushing elbow pain and shoulder instability due to your movement inadequacies! By screwing up the load ordering (elbow instead of shoulder), athletes have now lost valuable stability of the upper extremity; bleeding power and performance throughout the kinetic chain – and think this doesn’t carry over to other movements of the upper extremities? Think again bro, you move how you move.  Imagine starting in a poor shoulder position as an offensive lineman trying to block a large human coming at you – less than optimal loading results in poor performance and injury potential.

Dropping into a dip, push-up, or bench press with the elbows bending first is an immediate fault. Try this yourself: set up for a push-up in the mirror. As you initiate the movement, if your elbows shoot back or flare out first, that’s a fail. And once the elbows are loaded and the athlete tries to unload them, the shoulders come forward in the socket and destroy the anterior labrum and biceps tendon – not good.

Here’s the solution (these apply to push, press, and dip movements):
1) Organize the spine. Midline stability is ALWAYS priority #1. Squeeze the glutes and tighten the abs. Overextension of the spine can impact shoulder position creating loss of internal rotation.

2) Load the shoulders. Imagine separating the floor with your hands (read this on how to set-up your grip width) and having the cubital fossa facing forward – basically get your elbow pits facing forward. This will stabilize and activate the external rotators, helping to optimize the position of the shoulder in the socket prior to the movement.

3) Drop towards the floor with forearms vertical. This is huge – just as you’d keep your shins vertical during squatting, you must keep your forearms vertical to prevent dangerous elbow forces and over-tensionng the triceps complex. The athlete should think about pulling the body towards the floor/bar to load the shoulders first. Just as with squatting, the first 6-8″ of the movement is crucial. The body should move forward and over the hands/forearms to keep the center of mass over the hands and load the shoulder (and unload elbow and wrist). Athletes tend to drop straight down over the hands, causing the elbows to shoot back and breaking the vertical elbow rule. Instead, the body’s center of mass should move forward as you descend to maintain vertical forearms (note the differences in the relationship of my center of mass in the pictures above). This optimal position also helps to improve the concentric (or ‘up’) phase of the press and improve movement consistency and repeatability as the triceps are able to function as an elbow extensor without being over-tensioned.

4) Box push-ups in which a box (such as a shoe-box, phone book, etc.) is on the floor between the athlete and floor is a great way to teach the first 6-8″ of the movement. Motor control is huge here and that initial loading is crucial for optimal movement. This also allows adequate gradation depth of the movement (can do the same for dips, bench, etc. – get creative) to progress the athlete with emphasis on the initial 6-8″ of the movement. For athletes that struggle with this, I will have them practice creating an actively stable shoulder at the top of the push-up, dip, or bench prior to even initiating the movement.

Here’s the bottomline: athletes must be able to appropriately load order ALL movements and the upper extremities are no exception. Too many athletes (novice AND “experienced”) load presses/pushes/dips poorly resulting in ugly skill transfer to more dynamic environments causing broken performances and bodies. Try the steps above and post your results/thoughts to comments – let‘s optimize this movement!

-Seth