Bench Press Blowouts
Prevention and treatment
by Dr. Ken Kinakin
Every week, we at Testosterone receive a dozen questions about weight-training injuries, like "Hey, guys, it hurts when I do this." If this were vaudeville, or we were just plain smart-alecks, we'd reply, "Then don't do that!"
Instead, we remind the reader that we're not doctors and, even if we were, it would be tough to diagnose an injury though email. We then suggest that he go see a good doctor with experience treating athletes.
We know that it's not exactly what an injured bodybuilder wants to hear. Therefore, we've asked Dr. Ken Kinakin, one of the world's leading experts in weight-training injuries, to write a series of articles about preventing, diagnosing, and treating the most common types of gym blowouts.
In this first installment, Dr. Kinakin will discuss injuries that revolve around the bench press.
Big Bench, Big Pain?
"So, how much weight can you use for kickbacks?"
"A lot, dude. How much can you use for triceps pushdowns?"
"Man, I'm really weak right now, and I've got the big pushdown meet coming up next month!"
If you overheard the above conversation in your gym, you'd think, what planet are these guys from? Everyone knows that the bench press is one of the most highly-regarded exercises in the weightroom. In fact, most individuals measure their strength and, perhaps, their very manhood by how much weight they can bench.
This emphasis on the bench causes many people to push the training envelope in an effort to increase their poundages, often resulting in injury. The most common mistake is benching too often, which doesn't allow the muscles and ligaments to heal properly. With this overtraining syndrome, many areas of the shoulder are affected, causing injury and decreasing overall performance.
The following article offers help to ensure injury-free training or, if injury has already been sustained, what steps can be taken to correct it.
An Ounce of Prevention
One of the best ways to prevent injury when benching is consistent employment of excellent technique. Proper technique can be summarized in one word: control.
When bench pressing, it's extremely important that the weight is controlled by the lifter for the duration of the repetition. If the bar is descended too quickly, it can hit the chest in the wrong spot, causing improper ascension toward the abdominals, resulting in compensation by raising the hips. This automatically forces the bar to go back over the chest, improving the chances of completing the lift.
The correct way to do the bench press is to lower the weight to the chest in a controlled motion. Note that the motion is described as controlled, not slow. The bar can still descend at a rapid pace, but at a controlled rapid pace. Too much energy may be expended if the descent time is overly long. (In hypertrophy training, a slower negative can be beneficial; however, we're focusing on maximal lifts here.) For beginners, a slower pace is preferable to one that's too fast. Once the ability to control the lift at a slow speed is mastered, speed can be increased.
One of the best cues to learn how to maintain control is in grip strength. The harder the bar is squeezed, the more control is gained over the bar. Visualize making dents in the bar with your fingers, and the bar will become easier to control. For this reason, the false — or "thumbless" — grip (whereby the thumb is positioned on the same side as the fingers) isn't recommended.
Research has shown that bench numbers can be increased by up to 10% simply by improving grip strength. In addition, the thumbless grip increases the potential for injury. The bar can slip or flip out of your hands and land on your chest, marring your training program and causing beautiful women to laugh at you — not good.
Secondly, there's no rational reason to use the thumbless grip. Some individuals contend that it makes the exercise more "strict," an incorrect assumption. The preferable alternative is to use a full grip and a stricter technique, which will allow an increase in the amount of weight lifted. The thumbless grip also increases the likelihood of a wrist injury, as the wrist is kept hyperextended (bent backward) to allow the bar to rest in the palms of the hands. With enough weight and time, this grip will cause an injury.
The second area of discussion involves the relationship between elbow angle and body position. The question is whether the arms should be held close to the body or at 90 degrees from the body. The answer depends on the motivation for doing the bench press in the first place. If the goal is to increase bench press poundage, keep the arms closer to the body, usually at a 45-degree angle:
This technique allows a backward push at the very bottom of the bench press and utilizes the anterior deltoids, along with the chest.
If muscular development of the chest is the objective, then benching with the arms out at 90 degrees from the body will put more stress on the pectorals and, therefore, increase chest development:
Furthermore, varying the angle throughout your training cycle will achieve different effects.
Tell Me Where It Hurts
Pain felt during the bench can be caused by many different variables. To properly identify the factors involved, distinguish at which point in the range of motion the pain is felt. Feeling pain at the top of the bench is different than feeling it at the bottom. This holds true even when the pain is felt in one isolated area.
The bench press can affect the muscles, joints, nerves, ligaments, and bursa of the shoulders. The majority of bench press injuries are one-sided and normally occur on the side of the dominant hand. It may seem strange that an exercise utilizing both arms and shoulders equally would cause pain on only one side, and usually the stronger side. This pattern indicates that the bench press isn't the true cause of the problem, but merely exposing a preexisting problem.
If the bench press was the true cause of shoulder pain, it would be felt in both shoulders equally and simultaneously. Clinically, however, that pattern is rarely seen, leading to the conclusion that the majority of bench press pain is due to preexisting shoulder conditions, rather than the bench press itself.
Compare this pattern of exposure with the alignment of an automobile. When vehicle alignment is off, it goes unnoticed until a certain speed (stress factor) is reached, at which point the steering wheel begins to shake, exposing the alignment problem. At a speed of ten miles an hour, it's very rare that the steering wheel will shake, as there isn't enough stress being placed on the alignment.
Similarly, for weight trainers, symptoms won't be present in an individual who's capable of benching 300 pounds but is lifting only 50 pounds. Preexisting problems are only revealed when enough stress is present to induce symptoms.
Pain Patterns — The Evolution of Ouch
Pain usually begins slowly, with the trainer finding it manageable — until one day, enough pain is felt to inhibit benching altogether. The decision is made to stop training for a few days to allow the pain to subside. Occasionally, this plan works, until heavier weight is added to the bench, which causes the pain to flare up and interfere with the workout.
The next typical step is to stop training for a few more days and add a painkiller or muscle relaxant to the regimen. This allows the pain to be reduced or halted. However, strength loss and dysfunction are still present.
Consultation with other trainers in the gym will usually yield the diagnosis "rotator cuff syndrome." This is a term used in sports medicine to describe a pattern in which the muscles that support the shoulder are painful. These muscles — the supraspinatus, infraspinatus, subscapularis, and teres minor — are responsible, individually or combined, for producing rotator cuff syndrome.
If the trainer's pain pattern is due to a mild muscle strain alone, the condition will be corrected in a few weeks through rest. When rest doesn't correct the problem, other causes and treatments need to be considered.
Proper Diagnosis of Shoulder Pain and Injury
The first step in correction of pain and injury is a complete and thorough examination by a sports medicine physician, chiropractor, or physiotherapist. The examination should include an assessment of the shoulder, arm, pecs, and cervical and thoracic spine to determine if one or more of these areas is involved. All shoulder muscles must be checked with orthopedic muscle testing to determine if the pain is being caused by the muscles, joints, or nerves.
If the muscles are found to be weak in the shoulder joint, the pattern usually involves just the muscles and joint. If the muscles are weak all the way down the arm and into the wrist, the whole arm, upper back, and cervical spine may be influencing the weakness pattern. If this is the case, then all three must be treated simultaneously. The muscles, joint, and nerves must be treated first in order to restore strength prior to rehabilitation.
Too often, rehabilitation exercises are recommended for shoulder injuries which involve a dysfunctional shoulder joint due to muscles with excessive scar tissue and compromised muscular nerve supply. Once these problems have been corrected, rehabilitation is extremely effective. If the dysfunctional areas aren't treated, rehabilitation can have minimal to moderate results.
A dysfunctional muscle with excessive scar tissue due to years of heavy benching can't be strengthened properly. The same holds true for an unstable AC joint, or for compromised nerve supply to the pec due to a nerve entrapment in the neurovascular bundle under the collarbone.
The process of identifying and correcting areas of dysfunction, followed by rehabilitation, will result in complete restoration of function and strength. Rehabilitation alone will result in the pain returning when the trainer begins heavy benching again.
Treatments That Work
After treating hundreds of lifters, from novice level to world-record holders, I've found certain techniques to be very useful in the reduction of pain and improvement in healing, allowing lifters to successfully return to competitive lifting following injury. The typical pain and injury pattern involves an excessively scarred anterior deltoid, causing improper function, especially when stressed with a lot of weight.
The other muscle that's usually dysfunctional due to scar tissue is the subscapularis, located on the front of the scapula in the armpit. This muscle stabilizes the shoulder joint when pushing heavy iron.
The infraspinatus muscle in the back is an external rotator of the arm and usually becomes weak, creating more internal rotation than necessary. This pattern sets up altered biomechanics, leading to abnormal movement patterns which impinge on tissue, creating wear and tear in the shoulder joint. For strengthening the infraspinatus muscle, treatment incorporating rehabilitation tubing or dumbbell exercises are best.
This exercise for the infraspinatus is an external rotation of the arm in an abducted position. In English, the person does a double biceps pose and brings his forearm down while leaving his upper arm in the same place until the palm faces the floor and the forearm is horizontal. This is like doing a double biceps pose toward the floor. Then you rotate the arm back into a double biceps position again.
The best way to do this with resistance is to use a piece of rubber tubing or a cable machine that has an adjustable pulley height. Set the height of the pulley or tubing at shoulder level. Grab the handle in the position of a double biceps toward the floor, then rotate the arm until it's in a double biceps position. This works the external rotation, or infraspinatus:
In the shoulder joint, the AC joint absorbs a lot of force when benching, and it's easy to traumatize and create an instability in this area. Muscles that cross an unstable joint won't work properly and might cause pain. The instability may be caused by a weakness in the subclavius, the small muscle located directly under the collarbone.
The most effective treatment for muscular injury used in my practice is Active Release Techniques (ART), developed by Dr. Mike Leahy. This is a soft-tissue therapy which breaks down scar tissue in muscle, allowing the muscle to heal and function properly. Treatment incorporating ART and rehabilitation exercises can usually help stabilize the collarbone. If the AC joint is overstressed, certain taping techniques can allow it to heal and rehabilitate by strengthening the muscles that cross the joint.
It's imperative that the nerve supply to the muscles is unimpeded with no deficit in neurological impulses. The area that's commonly affected by poor nerve supply is in the upper back, or the upper thoracic region.
The upper thoracic region is greatly affected by benching, as all of your bodyweight plus the weight of the bar is placed on the upper back. This can lead to excessive pressure in the spinal column and cause what's known as a T4 syndrome. This syndrome is recognized by a misalignment of the fourth thoracic vertebrae (T4), which can cause the whole arm to decrease in strength. T4 syndrome is often overlooked. However, once that area is fixed, strength can be restored and pain decreased dramatically.
A chiropractic adjustment to the upper thoracic spine helps restore normal motion to the region and allows proper nerve function. Nerve entrapment may also be found in the armpit region, where the nerve travels with the blood supply. A nerve entrapment decreases the nerve's ability to move and slide properly, causing the nerve to decrease in strength, and is often characterized by a tingling sensation in the hand. Treatment with ART, once again, is one of the best ways to remove adhesions and entrapment.
Once the muscles, joints, and nerves function properly, follow with rehabilitation exercises for the shoulder and a slow introduction of benching with light weight. As the weight increases, seek treatment immediately to fix the area and assist the rehabilitation process if pain appears in any location. The entire process can take from a few weeks to a few months, depending on when the injury occurred and the amount of scar tissue that accumulates.
In the next installment, we'll examine low back and knee injuries due to squat training. Until then, train hard and healthy.
About the Author
Dr. Kinakin is the founder of the Society of Weight-Training Injury Specialists (SWIS). For more information on this and his virtual book, "The Encyclopedia of Weight-Training Injuries," read Chris Shugart's two-part Smart Training interview with Dr. Kinakin from Issue 74 of Testosterone, or visit the Powerlifting website. To find an ART provider in your area, call 719-473-7000.