About this episode
Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the anatomical & clinical considerations of the deltoid muscle in functional fitness, as well as the best ways to begin to train the deltoid in the gym. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app/switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ALAN FREDENDALL Good morning, PTonICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today here on the PT on ICE Daily Show. It is Fitness Athlete Friday. We talk all things CrossFit, powerlifting, Olympic weightlifting, endurance athletes. For that patient, athlete or client of yours that is recreationally active, Fridays are all about topics for that person. We are finishing out deltoid week here at ICE, so we're talking all things shoulder, in particular the deltoid muscle, exercises for the deltoid, manual therapy for the deltoid, so go back if you haven't been listening the rest of this week to all the episodes from all the other faculty, Monday, Tuesday, Wednesday, Thursday, dry needling techniques, cupping techniques, exercises, modifications, importance of deltoid exercises for pregnant and postpartum moms, we've got it all. Plus, we have a whole bunch of great content on our Instagram page as well, related to the deltoid and all of those topics. Today on Fitness Athlete Friday, we're going to tackle the deltoid from its role in functional fitness. So in particular, we're going to be talking about vertical pressing. So we're going to talk about anatomical considerations of the deltoid as it relates to lifting weights overhead. We're going to talk about clinical considerations of why do we care about someone's deltoid when they come in for physical therapy treatment. And then we're going to finish talking about how we think you should actually train the deltoid with these patients and athletes in the clinic. THE DELTOID: ANATOMICAL CONSIDERATIONS So a brief anatomy overview to start. What are our considerations for the anatomy of the deltoid? We need to understand and recognize the deltoid muscle is large, it is designed, it is built for blunt force trauma. If we come away from social media and computers, and the past 2000 plus years of human progress, and we go back to ancient man and even before we became humans and we were walking around on all fours, understanding the role of deltoid, but as we're crawling around on all fours, we have hip extension from our hip, we have glutes and quads as our primary lower extremity muscles, and in the upper body, we are pulling ourselves along the ground. We are designed for vertical pulling in particular, We all understand the importance of the lat. There's probably not a single person, if you walked into a room and recommended that the average person could benefit from doing some strict pull-ups, there's probably nobody that would voice opposition or concerns. But yet, when we start to talk about vertical pressing, all of a sudden, the conversation changes. Whoa, don't lift your arm overhead. That's dangerous. We've heard things, and I've heard things, like even when I was in school, that the shoulder is so mobile, it's just really not optimal to lift your arm overhead. Which, if we go back to our history and our evolution, doesn't really seem practical. And I think it's a fundamental misunderstanding. of how the deltoid functions and its role in providing that stability to the shoulder joint. So being quadruped, now bipedal organisms, now standing up resisting gravity, great at vertical pulling, not great at vertical pressing, especially when we don't do it. Why? The shoulder is inherently mobile, it is inherently unstable. It does not have a lot of bony support. The deltoid is the primary muscle that gives us that stability. throughout the whole range of motion of the shoulder. The deltoid is primarily responsible for flexion and abduction. It is the prime mover of shoulder elevation. And in particular, as we begin to approach 90 degrees of flexion and abduction and move up towards 120 degrees and beyond, the deltoid really becomes the only mover. A lot of the other smaller muscles, upper traps, rotator cuff muscles, whatever, really fall off and the deltoid stands alone as moving things overhead. And so we see that that does not happen. That does not happen in a lot of people. We already know most people are sedentary. They're not lifting weight overhead, pushing or pulling. But for those folks that are, we need to get them doing probably more vertical pressing to train that deltoid to really understand and respect the anatomy that we need to have a really strong deltoid if we really want to have a strong and stable shoulder. Really great evidence on the importance of the deltoid as the prime mover of the shoulder. An article back from 2021, the Journal of Elbow and Shoulder Surgery, Hecker and colleagues, Really cool study. They took people, they gave them an axillary nerve block on one side, and then they gave them nothing on the other side. And they tested maximal isometric strength. And what they wanted to find out is how much strength comes from each of the shoulder muscles, at what degree of shoulder flexion, shoulder abduction, internal or external rotation, adduction and abduction. And what they found is when they blocked the axillary nerve, and they tested isometric strength, instantly with the arm still at rest, moving into flexion, the shoulder strength was reduced to 76%. In flexion and in abduction, it was reduced to 64%. And now again, as we elevate that shoulder further up towards 90 to 120 degrees, the strength fall off was even more significant. Flexion now at only 25% strength, and abduction at 30 strength. So the deltoid is involved in the entire range of motion of primarily flexion and abduction. But in particular, as we get up towards 90, and as we start to bring our arm all the way overhead, it is primarily deltoid, which means we need to be training the full range of motion, and we need to be training more pressing patterns, and not so much laying on our back or laying on our stomach and doing prone rotator cuff work, trap work, whatever. That stuff is great early on in therapy, but if we really want to get the deltoid strong, we need to move it through the range of motion that it controls, which is all of it, and in particular, all the way up and overhead. THE DELTOID: CLINICAL CONSIDERATIONS So discussing clinical considerations, who might we see with a deltoid problem? How could we pick up that somebody might need to get stronger deltoids? I would argue just like with glutes or quads, it's every human being, right? There's no one that is checking the box on strong enough muscles. I don't think you'll find a single elite athlete who thinks, I don't need to train anymore. I've made it. They're probably always aware of their weaknesses and things they need to train. and I would argue vertical pressing, training the deltoid is true for every single person. But we do see these presentations come in. where we start to think, hmm, what I'm seeing, I think I'm treating the symptom of a bigger problem. So when the deltoid isn't doing its job, that's when the other smaller muscles of the shoulder complex take over. That's when we have people with upper trap stiffness or upper trap pain or headaches or posterior cuff pain or issues up in their neck, trouble with rotation, side bending, whatever. those smaller muscles that can act to elevate the shoulder are taking over because the deltoid isn't pulling its weight. The long-term solution isn't to only train those muscles, it's to train those muscles if it makes the person feel better, but again, get back to training the deltoid. So when we see those patients come in the clinic, oh, my traps, my traps, my traps, my traps, my neck is stiff, I've got a headache, and we start to dig into the subjective, what have you been doing? Oh, we've been doing a handstand push-up cycle at my gym. Oh, we've been doing a split jerk cycle, a clean and jerk cycle, a snatch cycle, whatever. you start to hear that this person has increased their volume and overhead lifting and they're complaining of all of these secondary symptoms of upper trap, neck, headache, whatever. When I hear that, I'm thinking this person, this person, yes, needs my help. reducing pain, restoring range of motion, but I'm also thinking, I need to get this person on a vertical pressing program. Especially a functional fitness athlete, I need to be getting them doing strict press, I need to be getting them doing handstand pushups, strict handstand pushups, whatever they can tolerate, wherever they're at in their fitness journey, maybe it's handstand pushup, eccentrics, whatever, but I'm thinking, we need to start integrating some vertical pressing in this person's program, because yes, while we're treating their symptoms short term, the way they're presenting tells me they would benefit a lot from stronger shoulders. These symptoms are probably going to be less likely to show up in the future if we do that. And so as we're reducing the symptoms, resolving the symptoms in the local tissue, we then need to evaluate if the deltoid needs strengthening. A lot of folks ask, how strong should your shoulders be? We have a lot of really great evidence on bodyweight normalized exercise in the lower extremity. We know the stronger your squat gets relative to your bodyweight, the less likely you are to develop lower extremity injuries. So the stronger a 1x bodyweight back squat, a double bodyweight back squat, stronger, stronger, stronger, less, less, less injury. We don't have a lot of that research in the upper extremities, but I would say that a strong person should be able to press 50-100% of their bodyweight overhead. Now that's going to depend on a lot of things. Training age, right? Somebody that just started lifting overhead six months ago is probably a very long time, like years or decades away from achieving a bodyweight strict press. Somebody that has been training a lot and is close is obviously going to get there a lot closer. But we don't necessarily need to get there with a strict press. Somebody that can push press their body weight, somebody that can jerk their body weight, somebody that can show me a strict handstand push up, that person really tells me that they have really strong shoulders. Arm length plays a big role here. Those of you with longer arms, I know you're listening right now, nodding your head. I'm five foot seven. I have these little T-Rex arms. I don't have a lot of range of motion before my arms are locked out overhead. Someone built like me. isn't actually going to have a stronger press, a stronger handstand push up capacity than someone that is six foot six and their fingertips touch the middle of their fibula, right? So consider that as well. Don't hold people's feet to the fire on that too much. But no, we want to see people getting a strong press, we want to see them move towards a 50% bodyweight press, and then continue to train that as much as possible. We have a number of different tools we can use as well to look for asymmetries in the clinic. I love to just stick with a dumbbell strip press in the front rack. Hey, let's try a five to eight rep max. Let's see if we have an asymmetry. If somebody can't tolerate that due to pain, I love to go to a landmine press and try to find a five to eight rep max there, and then try to see if I can observe any asymmetry. And then we know if we talked here on the past on the Daily Show, to clear up asymmetries, we need to be training the weaker side three to four times the volume. So that person needs to be doing maybe four to five sets of pressing work for every set that the strong side does. So that's always a consideration as well. When we look at ratios in the upper body, we need to understand the upper body is or at least should be a little bit weaker compared to our lower body. Humans are primarily legs. We do have those people out there. You probably all have a friend that has a 400 pound bench press and a 200 pound back squat. They're just built. They're built different, right? They love upper body, skip leg day a lot. But in general, our legs should be stronger than our upper body. How strong? About 40-60, maybe 30-70 at the most. But when you start to get to a ratio of 80% of my strength is in my legs and 20% is in my upper body, we really get into an issue where now our lower body can generate more power than our upper body strength can handle. And so we have some really cool research, Matt Sura and colleagues, 2023 Journal of Science and Medicine and Sport followed swimmers and asked that question in their research. Hey, is there a ratio where lower body strength leads to upper body injury? And the answer seems to be yes, which is really interesting research. So this study followed 48 competitive swimmers across six months. At the start of the study, these swimmers had no pain. Across the six months of training, 20 swimmers developed pain and the researchers testing baselines and reassessments throughout the study wanted to pick up on how can we determine who's most likely to develop a shoulder injury across a season of competitive swimming. And so finding that folks who developed a stiffer shoulder across those six months, worse posterior deltoid range of motion, And those folks who had higher ratios of lower extremity strength to upper extremity strength went on to develop pain. Their legs were able to generate so much power in the water that their shoulders were too weak to keep up. And over time, we're assuming and carrying forward that that led to overtraining essentially of the upper body. We can see that in the gym, with movements like push press or push jerk, we know the legs provide the majority of the motion and the power for those movements. And if our shoulders are not strong enough, yes, our legs can help us get that weight overhead. But if we're doing that a lot, and our shoulders are just not inherently stable, because we have a weak deltoid, then we can run into trouble where the ratio becomes so skewed that it can now be harmful. So I like to think of this is the legs begin to write checks that the shoulders can't cash, right, the shoulder is not moving through the full range of motion. And now those other muscles have to take over because that ratio is so skewed. And that's who shows up in your clinic door, right? I have stiff traps, I have a headache, I can't turn my head, I did a bunch of push jerk, I did a bunch of kipping handstand push ups, whatever, we need to treat that person's symptoms, we need to get their shoulders stronger, we need to control that ratio a little bit better. THE DELTOID: TRAINING So as we finish up here, how do we do that? How do we train the deltoid? A lot of people think they're training the deltoid, they think they're training shoulders, but they're not really doing it effectively, which is why they don't see a lot of results in whatever their goal might be for the shoulder, even if it's just to not have shoulder pain during exercise. And so we see a lot of what we might call bro shoulder press, right people sitting or standing in the gym. That arm is cocked out to 90 degrees of abduction and then they're kind of just pumping that weight up and down overhead, right? They're in a neutral grip. They're in a small amount of abduction They are technically in no flexion in a small amount of external rotation so in that movement that kind of seated or standing dumbbell press where the weight is just floating out in space is EMG studies would say that person is primarily training the triceps. If you ask that person in the moment, where do you feel this, they would probably tell you their triceps. And so getting people to understand what does deltoid training look like. is very important because some folks may think they're doing it, they may think they're doing a lot of it, and they're not. They're probably training triceps, they're probably primarily overloading a different muscle, which is just exacerbating the whole problem. They're probably allowing a dip in their legs in the strict press. So again, the legs are primarily generating the momentum for the movement. And they're probably just not performing full range of motion. And again, The deltoid is on the whole range of motion, especially at and above 120 degrees. So we need to be training full range of motion if we want a really strong, robust deltoid. Most people skip deltoid training completely, which is another factor, right? Coming into the gym and doing five by five strict press is not fun. It's not sexy. It's not as cool as ring muscle ups or a heavy deadlift or a heavy power clean or something like that, or even just doing push press or push jerk. It's more momentum. It feels cooler. You can lift more weight. And so strict press often gets left behind, which is the thing that some athletes and patients need to be training the most. Other athletes might be thinking, hey, I bench press a lot, I have strong shoulders, but when we look at studies of what muscles are active at what degrees of incline in a bench press, we see that we have to elevate that bench to almost 60 degrees just to begin to get a little bit of anterior delt work. And that we have to incline it to 90 degrees, which is, you know what, no longer a bench press, you are sitting upright, to begin to target the lateral and posterior heads of the deltoid. We had a cool study from Rodriguez, Redallo, and colleagues in the Journal of Environmental Research and Public Health in 2020 that looked specifically at that and said, hey, primarily in the bench press, even at an incline, you are still primarily targeting the pec muscles. Yes, at 60 degrees of incline, you begin to get more anterior delt, but bench press is for the chest, which some of you are saying, Alan, I knew that already before I listened to this podcast, but others out there might be thinking, hey, I thought that was also getting my delts. It's not. So we need to recognize that we cannot bench press our way to stronger deltoids. That will certainly get you a stronger chest, better push-up capacity and ability, but it will not do anything to really train your deltoids, and if that's a weakness area for you, help shore up that weakness. And so we need to get folks training shoulder flexion and shoulder abduction through the fullest range of motion possible, training them together. Yes, barbell strict press, alternating dumbbell press, standing, sitting, Z press, whatever. And in really, really being sticklers for people that they work the full range of motion. If you're going to use dumbbells, they need to start in the front rack position where the head of the dumbbell is on the shoulder, and you are pressing through 180 and 180 degrees of shoulder flexion and abduction. and you're not hanging out here and just giving it that little tricep hump that people like to do. Train the full range of motion. For those folks who are needing or wanting to do handstand pushups, handstand pushups are also a great way to train the vertical pressing pattern. If folks already have strict handstand pushup capacity, working at it as accessory work is great. Adding things like plates for a deficit will challenge bigger ranges of motion that will develop and continue to progress in a linear fashion vertical pressing, and deltoid strength. If they can't do strict, but they can kip, we can have them kick up to the wall, lower themselves through that range of motion, and do a handstand pushup negative. That is a great shoulder strengthener. I have a lot of athletes do that for accessory work. Even athletes that have strict handstand pushups and have good strict handstand pushup capacity, working that time under tension, especially if they can tolerate a deficit, is gonna make really robust shoulders, a really strong, healthy shoulder, And because they're training a deficit so often, when a workout shows up with regular handstand pushups or regular strict handstand pushups, those athletes fly through those workouts because their capacity has increased so much. At all costs with those folks, we want them to avoid kipping unless they're doing an eccentric, because again, that's the same as if they were standing up and doing a push press or a push jerk. We want to avoid having the legs help us train the shoulders. When we need to get strong shoulders, we should be training the shoulders. Folks can benefit a lot from complexes, things like doing a bunch of strict press followed by push press or push jerk. That is a great way to train the deltoid under fatigue, which relates a lot, especially to those athletes who are going to be using a lot of vertical pressing under cardiovascular fatigue. So one of my favorite ways to do that is 3 sets of 3 strict press, add some weight, 3 sets of 3 push press, add some weight, 3 sets of 3 push jerk. Starting fresh, working the deltoid, sets of 3, very heavy load, getting stronger. is the deltoid fatigues, using the legs a little bit to help it out with the push press, and as it gets really tired, using the legs even more in our push jerk. You'll find if you do a big complex like that, that your shoulders are tired, your shoulders are sore the next couple days, and that is really a unique feeling to have soreness in the deltoid that a lot of people don't experience because they're primarily not training the deltoid, or other muscles are taking over for them because their deltoid is so weak. For accessory work, the EMG exercise with the largest deltoid activation is a prone Y with the arm unsupported, moving in and out of 120 degrees of flexion abduction with the hand wound up and as much external rotation as possible. So that's from Mike Reinhold and colleagues, they have a bunch of research on EMG activation in the shoulder muscles. That's where the delt works the most out of a number of different exercises. So after training is done, after we've got our strict press or handstand push ups in, we can go to that prone Y do some burnout sets, something like that, and really begin to overload the deltoid in a way that facilitates a lot of strength. SUMMARY So the deltoid, largest or should be largest, strongest muscle in the shoulder built for work, built to move the shoulder through the whole range of motion, but only if we train it. Otherwise, those smaller muscles are going to take over. The shoulder is inherently unstable, that full 180 degrees of freedom. It doesn't have bony approximations that give it support as much as the hip or other joints, which means we need strong muscles, in particular, a strong deltoid to act as the stabilizers for us. In the clinic, we're primarily treating the aftermath of what happens to people when their shoulders are not as strong as other parts of their body, their legs, their traps, their posterior cuff, whatever. We need to clear up those local symptoms and then get that person on some sort of deltoid strengthening program so that the deltoid begins to do the work. Most folks will find that their capacity in the gym, in their fitness, often increases with overhead lifting, and they have less symptoms, less stiff traps, stiff neck, headaches, so on and so forth. A lot of folks have no issue doing vertical pulling. They might be doing vertical pulling multiple times per week, really training the lats, pull-downs, pull-ups, chin-ups, muscle-ups, whatever, but often they are avoiding vertical pressing, or they're using a variation of a vertical press where their legs help them a lot when they should be focusing on strict movements. Strict movements like strict press, strict handstand push-ups, and training the full range of motion. Remind these folks they are welcome to do as much bench press as they like, but you cannot bench press your way to a stronger deltoid. And when in doubt, again, keep it strict. So I hope this was helpful. I hope you have a wonderful Friday, a great weekend. If you want to join us online, our next cohort of fitness athlete level one online starts August 2nd. Fitness athlete level two online starts September 2nd. And then a couple chances to catch us out on the road. Zach Long will be teaching this weekend in Raleigh, North Carolina. And then in two weeks, we have the fitness athlete summit here in Fenton, Michigan at CrossFit Fenton. We'll have all four lead faculty from the division here, as well as our four teaching assistants, so our full staff will be on hand for that course. That's gonna be a lot of fun, so we hope to see you in two weeks here in Fenton. Have a great Friday, have a great weekend, bye everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.