By John Hofman
It is well documented that firefighting is a physically demanding job. Throughout your career, you will deal with some type of injury (i.e., lower back, knee, shoulder). Lower back injuries are ranked as the highest among musculoskeletal injuries, followed by knees and shoulders. Shoulder problems are starting to become more apparent with firefighters because of a number of factors such as a reduction in thoracic spine mobility, rotator cuff endurance, and scapula stability. These attributes develop over time because of the physical demands required during normal fireground operations. Poor exercise selection and technique in firefighter fitness programs could see an increase of shoulder injuries.
Many new types of training modalities are being exposed to the fire service. Everything from high-intensity training to multi planar, metabolic conditioning is being implemented so firefighters may improve on their fitness. Still, one-third of all injuries in the fire service resulted in physical exercise activities (1). Exercise like push-ups and pull-ups are very common within these types of modalities because of their simplicity and effectiveness, yet if performed incorrectly with repetitive motion, they will eventually cause pain or discomfort within the shoulder.
The shoulder is a unit composed of the shoulder joint and shoulder girdle, which requires a great amount of dynamic stability. The glenohumeral joint is a mobile system that is mostly controlled by the deltoid and the rotator cuff. The scapula is the anchor for the rotator cuff and creates stability within the joint. The main priority when using the shoulder is to have glenohumeral and scapula rhythm. Couple a muscular imbalance between them with high-repetition, high-intensity exercises, and injuries will occur.
The rotator cuff’s (RTC) primary job is to stabilize or center the humeral head within the socket when the arm is moving. When it no longer works properly, the deltoid will overpower it and force the humeral head to hit the ceiling of the joint socket, creating an impingement (which leads to a tear). It is recommended that you limit or eliminate any deltoid side raises and shoulder fly work if you currently have shoulder pain–you’re only going to make things worse. Remember, the RTC works as a whole: every time you raise your arm, all four muscles work, and it has a low-load threshold, so if you use it too much, you will injure it. When a tear occurs, the injured firefighter will not be able to stabilize the shoulder, forcing the scapula up, creating a shrug motion. Most RTC injuries do not just happen. They generally proceed through a progressive pathology that goes from irritation to inflammation to fraying to tearing.
Exercise such as kipping pull-ups, overhead press, or hand stand pushup should not be recommended for firefighters dealing with shoulder pain. Kipping pull-ups are a method of jerking and swinging your way through a pull-up vs. using the actual strength and power of your muscles to get your chin over the bar. This exercise requires strength and stability within the shoulder girdle and can be seriously exhausting to the muscles, joints, and connective tissue. Common injuries that have occurred from Kipping pull-ups and high-repetition, high-intensity movements are superior labrum from anterior to posterior tears (SLAP) and rotator cuff problems. SLAP tears occur within your labrum when it is subject to sudden stress, such as kicking out of the bottom of a pull-up. Pain will generally occur when you move your arm overhead (i.e., pulling ceiling), or throw (i.e., pulling hose).
Age and poor posture are two other contributing factors to shoulder pain. One-third of all firefighter injuries occur between the ages of 30-39. This is significant in the prevention of injuries because most males during this period begin to lose their flexibility, see a reduction in aerobic capacity, and gain weight. Over time, firefighters will also develop poor posture that can be attributed to the job. It is not uncommon to see a firefighter with the scapula protracted and anterior tilted because of wearing self-contained breathing apparatus. This position will decrease strength in the serratus and low traps and create tightness in the pectoral minor and upper traps.
Some of the more common injuries in the fire service are either related to pain in the acromioclavicular (AC) or glenohumeral joint. To help assess the shoulder, raise your arm above your head. If the pain is at the top, it is probably an AC joint problem (impingement); if the pain occurs while lifting your arm but goes away when you reach the top, it is probably a glenohumeral joint (rotator cuff) problem. Always refer to your medical professional for further evaluation.
Most firefighters will suffer from external impingement because of the constant overhead work found in firefighting. The pain is general caused by the following:
- direct pressure on the AC joint
- horizontal adduction (pull your arm across your chest) overhead motion
- horizontal pressing (i.e., bench press, push-up)
- periods of inactivity
- internal rotation.
If external impingement is the issue, the firefighter needs to modify the exercise programs accordingly:
- overhead activities
- modify / eliminate horizontal pressing (perform isometric hold push-ups with feet elevated or floor presses)
- incorporate more horizontal rows (TRX Low Row)
- incorporate more scapula-stabilization exercises (heavy farmers’ walk)
- soft tissue work and stretch the pectoral minor, teres minor, and lats.
- increase thoracic spine mobility (quadruped external rotation).
Rotator cuff problems are also very common in the fire service. They range from minor to severe. Specific pathologies associated with RTC problems are internal impingement, RTC tensile overload, and partial or full thickness tears. Most RTC injuries occur because of the following:
- exercises performed with high repetition and high intensity
- exercises performed at high velocity
- repetition and fatigue (arm fatigue and injury patterns).
To help reduce the chances of a shoulder injury, focus on creating rotator cuff balance by utilizing a 2:1 ratio of posterior to anterior exercises. Use external rotation more so that the low trap and serratus begin to work together when you raise your arm, increasing scapula stability so that it will anchor the rotator cuff, reduce any impingements, and develop dynamic stability. In addition, never work the rotator to failure.
Sample Program
Soft Tissue
Foam Roller: Lats, Pec Minor, Teres Minor
Static Stretch: Pectoral Minor, Lat, and Neck Flexors
Activation: Isometric hold push-ups with rhythmic stabilization (have someone gently push your body side to side, front and back while you maintain control–you should really feel your RTC working), Heavy Farmers’ Walk
Scapula Stabilization: “W” exercise (hands by your side and externally rotate your hands out so your elbows go down creating a W. You will feel it in your midback), Prone “Y” exercise.
External Rotation: Side-lying shoulder rotation (with a towel between your arm and torso).
John Hofman is the strength and conditioning coach for the Sacramento Fire Department, John oversees the Wellness Centre, coordinates the department’s medical and fitness assessments; develops recruit fitness training, pre-employment medical and fitness evaluations; and assists the department’s 20-certified Peer Fitness Trainers. In addition, John also works as the strength and conditioning coach for the California Regional Fire Academy, Sierra Fire Technology Program, Rocklin Fire Department, and South Placer Fire District. He also consults with the Fire Agency Self Insurance System of California.
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