Chronic Shoulder Impingement in Wrestling: Corrective Exercise Continuum as an Intervention

By Joshua Sansbury, ATC, MBA, CES, SCAT
Athletic Trainer
MUSC Health Sports Medicine

The sport of Wrestling can have a devastating effect on the joint health of each and every participant. Over time, athletes will develop daily joint pain from a wide range of scenarios. One of the most common of which is the development of Chronic Shoulder Impingement. As Wrestlers continue with the grind of training, weight cutting, and competition, one of the most overused and often abused joints, is the shoulder. A predisposing factor for shoulder impingement is Upper Cross Syndrome (UCS). Because of the correlation between shoulder impingement and upper cross syndrome, the use of the NASM's Corrective Exercise Continuum can be an effective part of a wrestler's treatment plan.

The Corrective Exercise Continuum is meant to correct altered joint kinetics caused by repetitive motion, utilizing a 4-part approach: inhibit, lengthen, activate, and integrate. The Corrective Exercise Continuum has been proven effective as treatment for patients with UCS. While not often the root cause of a wrestler's shoulder pain, Athletes who present with chronic shoulder impingement often display posture consistent with UCS. UCS posture presents with anterior and superiorly displaced shoulders, as well as winging scapula. This displacement of the shoulder can narrow the subacromial space, limiting space for the supraspinatus tendon, subacromial bursa and biceps tendon to operate. This limited space can have added stress on the anterior shoulder and aggravate impingement symptoms by causing friction in the subacromial space. As such, wrestlers who present with upper cross syndrome are more likely to develop shoulder impingement.

Wrestling is a challenging sport that operates along multiple planes of motion. Most action that involves the shoulder is anterior in nature, operating along the frontal plane. Anterior action in wrestling begins in the neutral position (on the feet) with clinch scenarios, all the way to bottom offense and defense alike. A common offensive bottom move, the Half-Nelson, protracts the attacker's shoulder to reach below the defensive wrestler's shoulder with the palm reaching for the opposite end of the neck. This causes the defensive wrestler to reach back, grab the hand and pull down towards their own chest. In both instances, wrestlers are using anterior movement patterns that can result in the anterior muscles of the shoulder becoming overactive. Over time, these movement patterns can lead to postural deficiencies associated with UCS.

Upper Cross Syndrome is caused by overactive muscles in the upper trapezius and pectorals, as well as underactive middle/lower trapezius, and rhomboids. These over and underactive muscles are antagonists that work together as force couples to generate proper joint kinetics. As wrestlers continue through the wear and tear of the season, trauma to the anterior shoulder can become more devastating. Because of limited space from shoulder posture as well as trauma from training and competition, wrestlers may begin to present with symptoms of impingement. Symptoms of impingement include pain with motion (particularly overhead), pain with palpation in the bicipital groove, loss of strength and function, and eventually numbness and tingling in the distal fingertips. When wrestlers begin to show the early signs and symptoms of impingement, the corrective exercise continuum can be an effective component to an athlete's treatment plan.

The corrective exercise continuum is a four part approach to correct altered length tension relationships. It begins with 1. Inhibition of overactive muscles. 2. Lengthening of overactive muscles. 3. Activation of under-active muscles. 4. Integration into full body motion.

Inhibition utilizes the autonomic nervous system through neuromyofascial release. In this phase clinicians can use, a foam roller, active release or passive release release therapy, or other more advanced techniques such as Graston. For impingement, the muscles to target are the pectoralis major/minor, and the upper trapezius. In this face, overactive muscles are "turned off", allowing knots in the muscle belly to release for a deeper stretch in the lengthening phase.

In the lengthening phase, the recently released knots in the upper trap and pectoralis are stretched. Stretching allows for tight muscles to lengthen to the end range of motion. Stretches can include humeral distraction for stretching the upper trap, and prone horizontal abduction to stretch the pectoralis muscles. By stretching the previously inhibited muscles, length tension relationships in the shoulder are alleviated.

In the activation phase, the middle and lower trap are activated through isometric activation. A wrestler should do 2 second isometric holds for 3 set of 15 reps at the end of range of motion for both the inferior trap and the middle trap. To best isolate each of these muscles an athlete should use a W (middle trap) and Y (lower trap) hold. By activating the under-active muscles, force couples in the shoulder are normalized through appropriate length tension relationships.

In the last phase, integration is used to train proper joint mechanics. Through integrated movement, athletes develop synergy in their previously antagonistic force couples. For a wrestler struggling with impingement, an appropriate integration exercise is a squat with an overhead press. As the wrestler begins to develop strength and proper joint mechanics, weight can be added.

Over time, these techniques will adjust the altered joint mechanics noted in a clinician's initial evaluation. By correcting altered length-tension relationships between under and overactive muscles, posture will improve as force couples begin to regulate. By alleviating the regular stress on the shoulder caused by poor posture and joint mechanics, the wrestler should begin to recover function while symptoms of impingement begin to fade.

This phenomenon is not unique to wrestling and can be noted in a wide range of sports, particularly overhead and contact sports. However, the regularity of this phenomenon in wrestlers cannot be overstated. With many of the most aggressive actions in wrestling being focused on the shoulder, the shoulder can take extensive trauma. It is not uncommon for wrestlers to develop guarding in their shoulder after an injury. Guarding can create unilateral shoulder posture consistent with UCS as well as causing secondary impingement. No matter the cause of UCS, athletes with chronic shoulder impingement should be treated with the corrective exercise continuum as a valuable component of a comprehensive treatment plan.