Shoulder Pain: The Indirect Approach

health , pain management , physical health

I developed shoulder impingement from Turkish Get-Ups - grinding through reps without the mobility or form to do them safely. Direct treatment didn’t help. The fix requires an indirect approach: restore thoracic spine mobility, loosen pecs and lats, then rebuild rotator cuff strength. The shoulder is a symptom of upstream problems - fix those first, and it often resolves itself.

How I Got Here: Turkish Get-Ups Gone Wrong

In theory, Turkish Get-Ups are one of the best exercises for shoulder stability. In practice, I didn’t have the mobility to do them properly, and I paid for it.

What went wrong: I was drifting my arm forward during the movement, struggling to keep it stacked over my shoulder. Without realizing it, I was compensating - getting stability by shrugging up with my trap instead of properly “packing” my shoulder. The cue “pack your shoulder” sounds simple, but when you’re self-training, it’s hard to know if you’re actually doing it or just muscling through with the wrong muscles.

The real mistake: I never dropped the weight while learning the movement. I kept grinding through with bad form, which meant every rep was reinforcing the wrong pattern and accumulating damage.

The fix I’m working through now: Drop the weight dramatically. Focus on feeling the shoulder packed - the humeral head pulled down into the socket, not shrugged up toward my ear. It’s humbling to work with a fraction of the weight, but it’s the only way to retrain the pattern without making things worse.

My Problem: Shoulder Impingement

My shoulder issue is impingement - the ball isn’t staying centered in the socket. Here’s the anatomy: your shoulder is a ball-and-socket joint where the humeral head (ball) sits in the glenoid (shallow socket). Unlike the hip which is a deep socket, the shoulder socket is shallow - more like a golf ball on a tee. This gives you huge range of motion but zero structural stability.

What keeps the ball in the socket? Your rotator cuff - four small muscles that wrap around the humeral head and actively pull it into the socket. When these muscles are weak or imbalanced, the ball migrates. Usually it drifts upward because the bigger muscles (deltoid, pecs) overpower the rotator cuff and pull the arm up.

What is impingement? When the ball rides high, it pinches the soft tissues (bursa, rotator cuff tendons) against the acromion (the bony shelf above your shoulder). Every time you raise your arm, you’re grinding these tissues. Pain, inflammation, and eventually tears.

Why stretching alone won’t fix it: Stretching addresses mobility but not the root cause - a weak rotator cuff that can’t keep the ball centered. You need to strengthen those small stabilizer muscles so they can do their job of pulling the humeral head down and in.

The fix:

  1. Restore mobility first - If your T-spine and pecs are tight, your shoulder blade can’t move properly, forcing the ball into bad positions
  2. Strengthen the rotator cuff - External rotation exercises, especially with the arm at your side and at 90 degrees
  3. Train scapular control - Your shoulder blade needs to move in sync with your arm; wall slides and prone exercises teach this
  4. Avoid overhead work until stable - Pressing and reaching overhead with a migrating ball just accelerates the damage

Shoulder Movement Directions and Muscles

Before diving into the fix, here’s the vocabulary of shoulder movements. Understanding these directions helps you know what you’re working on.

Flexion (raising arm forward and overhead):

  • What it looks like: Arm moves from your side, forward, and up toward the ceiling (like raising your hand in class)
  • Muscles: Anterior deltoid (front of shoulder), upper pec, biceps (long head)
  • Common exercises: Front raises, overhead press

Extension (moving arm backward):

  • What it looks like: Arm moves from your side backward behind you (like reaching for your back pocket)
  • Muscles: Lats, posterior deltoid (rear shoulder), teres major, triceps (long head)
  • Common exercises: Pull-ups, rows, straight-arm pulldowns

Abduction (raising arm out to the side):

  • What it looks like: Arm moves from your side, out to the side, and up overhead (like making a snow angel)
  • Muscles: Supraspinatus (rotator cuff) initiates 0-15°, then middle deltoid takes over
  • Common exercises: Lateral raises, overhead press
  • Critical: Your shoulder blade MUST rotate upward or you get impingement

Adduction (bringing arm down to your side or across body):

  • What it looks like: Arm moves from overhead or out to the side, down toward your body
  • Muscles: Lats, pecs, teres major
  • Common exercises: Pull-ups, lat pulldowns

External Rotation (turning arm outward):

  • What it looks like: Elbow at your side, bent 90°, forearm rotates away from your body (like opening a door)
  • Muscles: Infraspinatus, teres minor (both rotator cuff muscles)
  • WHY THIS MATTERS: This is THE critical movement for fixing impingement. Most people are weak here.
  • Common exercises: Side-lying external rotation, face pulls

Internal Rotation (turning arm inward):

  • What it looks like: Elbow at your side, bent 90°, forearm rotates toward your body (like closing a door)
  • Muscles: Subscapularis (rotator cuff), pecs, lats
  • Note: Usually overtrained from push-ups, bench press, desk work. Most people don’t need MORE internal rotation.

Horizontal movements (arm at shoulder height):

  • Horizontal abduction (pulling back): Rear delts, rhomboids, mid-traps - like reverse flyes
  • Horizontal adduction (pulling across): Pecs, anterior delt - like cable crossovers

What matters most for fixing impingement:

  • External rotation - Weak in almost everyone, essential for centering the ball
  • Scapular control - Depression and retraction, the foundation for everything
  • Avoid excessive internal rotation - You’re probably already too internally rotated

Key Muscles and Their Roles

Now that you understand the movements, here are the muscles that make them happen - and their specific roles in shoulder health.

The Rotator Cuff (SITS) - Your Stabilizers

These four small muscles wrap around the humeral head and are the only thing keeping the ball centered in the socket. If they’re weak, the ball migrates and you get impingement.

Supraspinatus (top of shoulder):

  • Job: Initiates abduction (first 0-15° of raising arm to side), pulls humeral head DOWN into socket
  • Problem when weak: Ball rides up, impingement starts immediately when raising arm
  • Common issue: First to get injured, prone to tears from overhead work
  • Test: Empty can test - arm straight out to side at 30° forward, thumb down (like emptying a can), raise 12-15 times with 2-5 lb weight. Pain or inability = weakness or injury.

Infraspinatus (back of shoulder):

  • Job: External rotation, pulls humeral head DOWN and IN to center it
  • Problem when weak: Ball drifts forward and up, you lose external rotation range
  • Critical: This is THE muscle to strengthen for fixing impingement
  • Test: Elbow at side bent 90°, externally rotate against resistance (band or partner’s hand). Can you do 15+ reps without shoulder hiking up toward ear? If shoulder elevates or you compensate = weak.

Teres Minor (back of shoulder, below infraspinatus):

  • Job: External rotation, assists infraspinatus in pulling head down
  • Problem when weak: Same as infraspinatus - ball migrates forward/up
  • Note: Functionally very similar to infraspinatus - think of them as a team like biceps short head and long head. Anatomically distinct muscles, but in practice they fire together during external rotation. Almost impossible to isolate or test separately.
  • Test: Same as infraspinatus test - works together with it.

Subscapularis (front of shoulder, against ribcage):

  • Job: Internal rotation, pulls humeral head forward INTO the socket (anteriorly)
  • Problem when weak: Ball can drift backward (rare)
  • Problem when tight: Restricts external rotation, contributes to forward shoulder posture
  • Note: Usually NOT weak - gets plenty of work from push-ups, bench press
  • Test for tightness: Lie on back, arm out to side at 90°, elbow bent 90°. Let forearm drop back toward floor. If forearm can’t reach horizontal or beyond = tight subscapularis.

The Deltoids - Your Prime Movers

The three deltoid heads are the big muscles that actually move your arm. They’re strong, but if the rotator cuff is weak, they’ll yank the ball out of position.

Anterior Deltoid (front):

  • Movements: Flexion (raising arm forward), assists internal rotation
  • Problem: Often overdeveloped from pressing movements, contributes to forward shoulder posture
  • Balance check: Can you do as many overhead presses as bench presses?

Middle Deltoid (side):

  • Movements: Abduction (raising arm to side)
  • Critical coordination: Works with supraspinatus - supraspinatus starts 0-15°, middle delt takes over
  • Problem: If supraspinatus is weak, middle delt takes over too early and yanks the ball upward
  • Test: Lateral raises with 5-10 lb dumbbells for 12-15 reps. Watch for shoulder hiking up - if it does, middle delt is compensating for weak supraspinatus.

Posterior Deltoid (rear):

  • Movements: Extension (arm backward), external rotation, horizontal abduction
  • Problem when weak: Can’t counteract forward pull from anterior delt and pecs
  • Test: Reverse flyes - bend forward 90°, arms hanging, raise arms out to sides. Can you do 15 reps with 5-10 lbs keeping shoulder blades squeezed? Weak = can’t complete reps or upper traps take over.

Scapular Stabilizers - Your Foundation

The shoulder blade is the platform the ball-and-socket sits on. If the platform doesn’t move correctly, the joint can’t work properly.

Trapezius (upper, middle, lower - three distinct sections):

  • Upper trap: Elevates shoulder (shrugging) - usually overactive, pulls shoulder up toward ear
  • Middle trap: Retracts scapula (pulls shoulder blade toward spine) - usually weak
  • Lower trap: Depresses and upwardly rotates scapula - CRITICAL for healthy overhead movement, usually very weak
  • Key insight: Most people are upper-trap dominant. You need to strengthen mid/lower trap to balance this.
  • Test for middle trap: Lie face down, arm out to side at 90°, thumb up. Lift arm while squeezing shoulder blade toward spine. Can you hold for 30 seconds without cramping? Weak = can’t hold or upper trap takes over.
  • Test for lower trap: Stand, raise arms overhead in Y position. Can you hold 60 seconds without shoulders hiking toward ears? If shoulders elevate = weak lower trap, overactive upper trap.

Rhomboids (between shoulder blades):

  • Job: Retract scapula, pull shoulder blades together
  • Problem when weak: Shoulder blades wing out, scapula sits too far forward
  • Test: Can you squeeze your shoulder blades together and hold for 10 seconds?

Serratus Anterior (side of ribcage, wraps around):

  • Job: Protracts scapula (pushes it forward), upwardly rotates scapula
  • Critical for: Push-ups, punching, reaching forward, overhead movements
  • Problem when weak: Scapular winging (shoulder blade sticks out like a wing), can’t push overhead properly
  • Test: Push-up position - do your shoulder blades stick out off your back?

Problem Muscles - Usually Too Tight

These large muscles get strong and tight from modern life and common exercises. When tight, they pull the shoulder into bad positions.

Pectorals (chest - major and minor):

  • Movements: Internal rotation, adduction, horizontal adduction
  • Problem: Desk work, driving, bench press all shorten pecs. Tight pecs pull shoulder forward and internally rotated.
  • Result: Rounded shoulder posture, restricts external rotation, forces humeral head forward
  • Fix: Stretch them (doorway stretch, box stretch), don’t do MORE pressing
  • Test for tightness: Stand in doorway, arm on doorframe at 90°. Step through doorway - you should feel a stretch across chest. If no stretch or can’t get arm back to doorframe = very tight pecs.

Latissimus Dorsi (lats - broad back muscle):

  • Movements: Extension, adduction, internal rotation
  • Problem: Pull-ups, rows, and sitting all tighten lats. Tight lats restrict overhead range.
  • Result: Can’t raise arms fully overhead without arching back, pulls shoulder down and forward
  • Fix: Lat stretches (box lat stretch), eccentric pull-ups for lengthening
  • Test for tightness: Lie on back, raise both arms overhead toward floor behind you, keep low back flat on ground. Can’t touch floor with arms or back arches = tight lats restricting shoulder flexion.

Teres Major (small muscle near lat):

  • Movements: Extension, internal rotation
  • Problem: Functions like a “mini lat” - often tight alongside lats
  • Result: Restricts overhead movement
  • Test: Same as lat test - functions as a unit with lats, difficult to isolate.

Key Principle - The Imbalance:

Modern life creates:

  • Too much: Internal rotation (pecs, lats, subscapularis), upper trap dominance, anterior delt work
  • Too little: External rotation (infraspinatus, teres minor), scapular retraction (mid/lower trap, rhomboids), scapular depression (lower trap)

The fix isn’t just “strengthen everything” - it’s specifically addressing this imbalance.

The Indirect Approach

You can’t fix shoulder directly. You need to go through this sequence:

  1. Improve Thoracic Spine Mobility
  2. Improve Pec and Lat Mobility
  3. Build Scapular Control
  4. Strengthen Rotator Cuff - External Rotation
  5. Maintain the length you’ve gained
  6. Wall Slides - The Final Boss

Step 1: Thoracic Spine Mobility

The thoracic spine (mid-back) is designed to rotate and extend. When it gets stiff, the shoulder compensates and gets overworked.

Exercises:

  • Small crunches over a peanut - Two lacrosse balls taped together, roll up and down the T-spine doing small crunches
  • Prayer stretch on foam roller - Kneel with elbows on roller, hands together, sink chest toward floor
  • Box T-spine stretch (more intense) - Put elbows on box while holding a broom stick, press down
  • Deep squat rotations - In a deep squat, rotate one arm up toward the ceiling while the other stays on the ground

Step 2: Pec and Lat Mobility

Once the T-spine moves better, address the pecs and lats which often pull the shoulder forward into bad positions.

Exercises:

  • Box lat stretch - Kneel facing a box, put elbows on box with palms together, sink hips back
  • Eccentric slow pull-up - Jump to top of pull-up, lower yourself as slowly as possible (5-10 seconds)

Step 3: Scapular Control

Your shoulder blade (scapula) is the foundation for healthy shoulder movement. The ball-and-socket joint sits ON the scapula, so if the scapula is in the wrong position or doesn’t move properly, the ball can’t track correctly in the socket.

The problem: Most people have scapular dysfunction - shoulder blades that sit too high (elevated), too far forward (protracted), or don’t rotate upward when raising the arm. This forces the humeral head into bad positions and creates impingement.

What you need:

  • Scapular depression - Pull the shoulder blade DOWN, away from your ear. This creates space under the acromion and prevents pinching.
  • Scapular retraction - Pull the shoulder blade BACK toward your spine. Counteracts the forward-rounded posture from desk work.
  • Upward rotation - The shoulder blade has to rotate upward as your arm goes overhead. If it doesn’t, you’re grinding bone on bone.

Exercises:

  • Scapular wall slides - Stand facing wall, arms overhead, slide down while actively pulling shoulder blades down and together
  • Prone Y raises - Lie face down, arms in Y position overhead, lift arms while squeezing shoulder blades down and together (not up toward ears!)
  • Dead hangs - Hang from pull-up bar, actively pull shoulders DOWN (scapular depression). Feel the stretch, don’t just dangle.
  • Band pull-aparts - Hold resistance band, pull apart while squeezing shoulder blades together, keep shoulders DOWN

Key cue: “Shoulders down and back” - This isn’t just a posture cue, it’s the actual scapular position you need to train.

Step 4: Rotator Cuff Strengthening - External Rotation

This is THE critical step for fixing impingement. The rotator cuff’s job is to pull the humeral head down into the socket and keep it centered. When these muscles are weak, the ball migrates upward and you get pinching.

Why external rotation matters most: Modern life creates massive internal rotation dominance. Desk work, driving, push-ups, bench press - all internal rotation. Your pecs and lats get strong and tight, pulling your arm forward and inward. The posterior rotator cuff (infraspinatus, teres minor) gets weak and overstretched. This imbalance lets the humeral head drift forward and up into impingement territory.

The fix is simple but tedious: Train external rotation with light weight, high reps, frequently. This isn’t about ego - you’ll use embarrassingly light weight. A 5-10 pound dumbbell is typical. The goal is to build endurance in small stabilizer muscles, not to lift heavy.

Exercises:

Side-lying external rotation (fundamental movement):

  • Lie on your side, bottom arm tucked under head
  • Top arm bent 90°, elbow pinned to your side
  • Hold light dumbbell, rotate forearm up toward ceiling
  • Key: Keep elbow GLUED to your side, only the forearm moves
  • 3 sets of 15-20 reps, multiple times per week

90/90 external rotation (arm abducted position):

  • Lie on your side, upper arm out perpendicular to body, elbow bent 90°
  • Rotate forearm up toward ceiling
  • This trains external rotation with the arm in a more vulnerable position (mimics overhead movements)
  • 3 sets of 12-15 reps

Face pulls (compound movement):

  • Cable or band at face height
  • Pull toward face, separating hands and rotating arms outward
  • Finish with hands by ears, thumbs pointing back
  • Trains external rotation PLUS scapular retraction and rear delts
  • 3-4 sets of 15-20 reps

Banded external rotation at side (warm-up/daily maintenance):

  • Band anchored at elbow height, stand sideways to anchor
  • Elbow bent 90°, pinned to side
  • Rotate arm outward against band resistance
  • Can do this daily as prehab before workouts
  • 2-3 sets of 20 reps

Programming notes:

  • Frequency matters more than intensity - 3-4x per week minimum
  • Always do BEFORE pressing movements (bench, overhead press) as prehab
  • Use tempo: 2 seconds up, pause, 2 seconds down
  • If you feel it in your trap or shoulder top, you’re compensating - lighten the weight
  • Progress is slow - expect 6-12 weeks before you notice significant improvement

Step 5: Maintain the Length

After creating mobility, you need to maintain it with daily movement.

Exercises:

  • Half prone angel - Lie face down, arms out to sides, slowly raise arms while squeezing shoulder blades
  • Shoulder swims - Lie face down, arms overhead, “swim” them down to your sides and back up

Step 6: Wall Slides - The Final Boss

Wall slides are both a diagnostic tool and the graduation test. They combine everything you’ve built in the previous steps into one integrated movement. If you can’t do them smoothly, they show you exactly where your limitations are.

What wall slides require:

  1. T-spine extension - to keep your back flat against the wall
  2. Scapular upward rotation - shoulder blades have to rotate smoothly as arms go up
  3. External rotation - to keep arms against the wall throughout the movement
  4. Rotator cuff control - to keep the humeral head centered (no pinching)
  5. Pec/lat length - tight pecs or lats prevent arms from staying against the wall

How to do them:

  • Stand with back against wall
  • Put arms against wall in “W” or “goal post” position (elbows bent 90°, upper arms out to sides)
  • Slide arms up overhead while keeping your back, head, and arms in contact with the wall
  • Slide back down
  • Repeat for 10-15 reps

What goes wrong if you have limitations:

  • Back arches off wall → Stiff T-spine
  • Arms pull forward off wall → Tight pecs, weak external rotators
  • Pain in shoulder → Rotator cuff still weak, ball migrating up
  • Can’t get arms overhead → Tight lats or poor scapular upward rotation

If you can do 15 clean reps with full range, arms and back staying on the wall, no pain - your shoulder is working properly. That’s the graduation test.

Heavy Clubs for Shoulder Health

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Heavy clubs are excellent for shoulder mobility and strength. They replaced KB halos in my routine because they provide better shoulder mobility work plus grip and core benefits.

Inspiration: Amazing Shoulder Control

This woman demonstrates exceptional shoulder mobility and control - watch how her shoulders move independently with complete control and range of motion. This is the kind of shoulder health and mobility you’re working toward.

See Also

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