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Letters to the Editor |
Rochester, Minnesota
Dear Editor:
We wish to congratulate Fees et al. on their recent review of weight-training modifications for injured athletes ("Upper Extremity Weight-Training Modifications for the Injured Athlete: A Clinical Perspective," September/October 1998, pages 732–742). Most of the suggestions pointed out are well supported by basic anatomy and physiology. In particular, the authors are to be commended for condemning the behind-the-neck latissimus dorsi exercise and recommending very limited use of the behind-the-neck deltoid press. We agree with their concerns. As a point of clarification, in the case reported by Shea1 the patient sustained a cervical spinal cord injury resulting in permanent tetraplegia rather than transient upper extremity paralysis. Certainly, a single case report is not conclusive evidence that the behind-the-neck latissimus dorsi pull-down exercise is dangerous; however, this tragic case underscores the critical importance of proper technique. Because of the potential for injury due to improper technique, a careful exercise prescription is critical.
As the authors have pointed out, the bench press exercise places an enormous stress on the shoulder complex. However, the authors did not describe the mechanical disadvantages that develop when the bar is lowered completely to the chest during the bench press exercise. In such a position, the pectoralis major muscle may be excessively elongated.2 A state of "active insufficiency" occurs as the result of inadequate actin-myosin cross-bridge formation in the pectoralis muscle. This places the athlete in a vulnerable position requiring the substitution of other secondary muscles (such as the anterior deltoid) to initiate the press phase of the lift. Additionally, significant shear load is placed on the acromioclavicular joint. This may contribute to degenerative changes and distal clavicular osteolysis. To minimize the risk of additional injury, it is recommended that the descent phase of the bench press exercise end approximately 4 to 6 cm from the anterior chest.
Regarding the back squat exercise, the authors suggest that persons with anterior shoulder instability may be unable to complete the exercise because of the "high five" position used to hold the barbell. A simple modification that can reduce the degree of external rotation of the shoulder is to advise athletes to spread out their grip. With a wider grip there is less adduction and external rotation at the shoulder, and the longer lever arm contributes to increased bar control and stability.
Finally, the authors mention "safe" weight machines. It should be stressed that without proper technique, no machine is truly safe. Patients with anterior shoulder instability should avoid latissimus dorsi pullover machines. This exercise can result in extreme shoulder external rotation and abduction. This is a position of vulnerability for a person with anterior shoulder instability.
Overall, the authors did an excellent study, and we congratulate them on an excellent review.
REFERENCES
Newark, Delaware
Dr. Reeves and colleagues underscore many of the points my coauthors and I made in the article. We concur with most of their comments, but must respectfully disagree with some of their conclusions.
Point 1. Although it is true that pectoralis major muscle ruptures can occur during a bench press, they are very rare. Fewer than 150 weight lifting-related ruptures of the pectoralis major muscle have been reported in the literature, while hundreds of thousands of bench press repetitions are performed each day.1,2 We agree that a phased return to the bench press (including the limited range of motion component; see Table 3 on page 735 of our article) is critical to safe functional progression. We do not, however, agree that the incidence of pectoralis major muscle rupture requires the wholesale abandonment of the most popular lift in the gymnasium.
Point 2. We have several concerns with the recommendations of Reeves and colleagues about advising athletes to "spread out the grip" in a back squat. First, wider grips are not a priori safer than narrow grips. Narrow hand spacing in the back squat yields 20° to 30° of abduction and full external rotation, while a wider grip increases the abduction component to 50° to 90° with full external rotation. The increased abduction and external rotation places the shoulder closer to the unsafe "high five" position. In addition, as the hand moves away from the body to establish a wider grip, it comes closer to the weighted part of the bar, leading to increased torque at the shoulder. Second, the primary purpose of a close grip during the back squat is to develop a position of scapular retraction. This allows the upper back musculature to remain stable and erect during the back squat movement (that is, maintain a flat, erect spine). The scapular retraction also provides a "shelf" for bar positioning. The shelf is physically developed by the scapular retraction and cushioned by the trapezius muscle. If the grip is moved outward, the shoulder blade is moved into a protracted position and the trapezius muscle is stretched, yielding little physical restraint by the scapula and cushioning by the trapezius muscle. Finally, in the article we gave several modifications (front squats and modified center of gravity bar) that are completely safe for the shoulder and target the appropriate muscle groups.
My coauthors and I concur with Reeves and colleagues about the pullover machine: it is unsafe for those with shoulder instability. We thank Dr. Reeves and his colleagues for their comments.
REFERENCES
This article has been cited by other articles:
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  J. Petilon, D. R. Carr, J. K. Sekiya, and D. V. Unger Pectoralis Major Muscle Injuries: Evaluation and Management J. Am. Acad. Ortho. Surg., January 1, 2005; 13(1): 59 - 68. [Abstract] [Full Text] [PDF]
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