Jared Powell:
Two friends go out for dinner. They order a chicken curry to share. It happens to be laced with peanuts, though neither of them knows it. One of them is allergic to peanuts. Pretty soon, that one is violently ill. The other friend eats the curry, enjoys it, and doesn't think about it again. So we have the same chicken curry, but two completely different outcomes. What happened?
Jared Powell:
Did the peanut do something wrong? Not quite. The peanut is exactly the same, humble peanut. It always was and always will be. The problem only emerged when that peanut meets a person who can't tolerate it. Moving on from this admittedly pretty weird and esoteric and slightly batshit crazy anecdote for a minute, because we're about to bring it back to something that has nothing to do with food. The upright row exercise, no other exercise in musculoskeletal rehabilitation inspires the same raw emotion of hate as the upright row does. So quickly, if you're new here, I'm Dr. Jared Powell, and welcome to the Shoulder Physio Podcast. And occasionally in this podcast, I like to go hunting for zombie ideas in musculoskeletal rehabilitation. Today's target is the demonization of certain exercises, and we use the upright row as a case in point. So if you've spent any length of time around popular fitness content online, first of all, I feel sorry for you.
Jared Powell:
Second of all, I'm in the same boat, but you've no doubt seen someone declare with absolute conviction that the upright row is the single worst exercise you can do for your shoulder. Worst, full stop, no exceptions. One particular annoying creator, , who will remain nameless, put it like this, and I'll quote it word for word so I do them justice and I'm not misinterpreting them. So in regards to the upright row, you may not pay for it now or tomorrow, but you will pay for it. That's a prophecy. Where is this confidence coming from? Others go further and say that doing the upright row will certainly land you in surgery at some point in time. Again, a prophecy. What is the basis of this definitive claim? What has everyone got against the upright row? So that's today's zombie idea, the idea that a single exercise performed by anyone in any context carries an inherent danger.
Jared Powell:
Let's see how that holds up to scrutiny. Okay, so why does anybody believe this? So to be fair to the fear mongers out there, there is a logic here. So let's pull that logic thread for a minute. At the top of an upright row movement, your arm is abducted and internally rotated. That I completely accept. That is anatomy 101. This position does look like the position used in the Hawkins-Kennedy special test, which is a classic clinical test for subacromial impingement syndrome.
Jared Powell:
So therefore, the argument runs, if that position in the upright row is literally the test for impingement, then repeatedly loading that position must be causing impingement, which then will cause pain. So test position equals injury position, which means upright row bad. That is the argument. I'm not gonna lie, it's a neat piece of reasoning. It has mechanistic plausibility. It sounds grounded in anatomy, and it's the kind of explanation that travels pretty well on social media because it's simple and it's scary. It's provocative. It gets the people going. To borrow the famous quote from Will Ferrell. However, there's just one problem. The entire argument is built on a foundation that has been refuted. The subacromial impingement model, the idea that shoulder pain is primarily caused by tendons getting mechanically squeezed, pinched, or abrased under the acromion during certain movements, such as any shoulder elevation, has near zero credibility at this point in time.
Jared Powell:
This theory has had a pretty challenging 10 years, to put it mildly. We know that structural findings on scans don't reliably track with pain. Surgery designed to create more space under the acromion, don't consistently outperform doing nothing surgical at all, not even a placebo or a fake surgery. Go read the seesaw trial from 2018 if you want more info on that. I, along with many other shoulder researchers, notably Professor Jeremy Lewis, have already spent far too much time pointing out the shortcomings of this theory and it is not in the scope of this episode to painstakingly go through it. So I'm not gonna waste any more time on it. However, if you are interested, just go down to the resources section of this episode for some light reading. Back to the upright row. So if that foundation is gone, then the argument built on top of it, this position resembles an impingement test, therefore th- this exercise causes impingement, therefore never do it, doesn't have anywhere left to stand.
Jared Powell:
You can't manufacture or borrow credibility from a theory that's pretty well dead and buried. So here's the second problem. Even setting the impingement model aside entirely, which we can't really do, but let's say for, for argument's sake we can, there is no direct evidence that upright rows increase your risk of shoulder pain or injury. Zero. The claim is not only built on a shaky mechanism, the impingement model, it's also not backed by any outcome data showing the exercise itself is dangerous. And if you consider how injury prediction works, and once you look at how injury prediction works, the claim gets shakier still. Roldbar, writing in the British Journal of Sports Medicine in 2016, reviewed screening tests designed to predict injury and found they essentially don't work and probably never will because injury is shaped by far too many interacting variables to be captured by a single test or a single movement pattern.
Jared Powell:
This is one of my favorite papers, again, published a decade ago by Roldbar in BJSM. Go and give it a read. And here's another study that I really love. It's a 2020 study by Marsh and colleagues published in the Journal of Physiology. And it was part of the Struth study, which is one of my favorite study names being an Aussie and Struth is a favorite slang word in our language. So they put identical twins through the exact same exercise stimulus. So identical twins through the exact same exercise stimulus. So these twins obviously had the same genetics and then they performed the same exercise. And what they found was pretty insane. They still got meaningfully different fitness and strength responses. So if genetically identical humans respond differently to an identical training stimulus, how exactly is a YouTube video meant to predict how your shoulder with your individual loading history, your individual tissue capacity, your individual sleep, your stress, how is a YouTube video going to predict how your shoulder is going to respond to a barbell moving in an upright row direction?
Jared Powell:
Hopefully you can see the folly of this definitive claim. Moreover, another great study that I liked by Stern et al in 2020 suggests that injury isn't a single cause event. They reckon it's a nonlinear process shaped by a tangle of interacting determinants. And I love that sentence, shaped by a tangle of interacting determinants. And so reducing that down to this exercise or this position, , equals this outcome always is a massive oversimplification to put it mildly. So this brings us back to the chicken curry that we opened this episode with. The upright row doesn't have some fixed essence of good or bad baked into it. Its effect emerges from the interaction between the exercise itself and the person doing it. So this might include their rotator cuff health, their loading history, their age, their prior experience with the movement itself. Again, like I mentioned before, their sleep and their psychological state, even how much they've been told to fear it.
Jared Powell:
None of these factors can be standardized across everybody on the planet. So what we can say pretty confidently at the moment is that same exercise and different people often equal different outcome. There is no moral claim of superiority of exercise type for musculoskeletal pain as far as we know at the time of speaking or writing. So this isn't really just anything goes. Exercise dosage still plays a very important role. I don't want to drift into nihilism here. So if you were to hand an untrained individual a 100 kilogram bench press, then you will have a proper injury risk and I can attest to that personally. Furthermore, if you hand that same untrained person a 20 kilogram upright row, you've got to have a proper injury risk again. But I want you to notice what's happening in both of these cases. It's an absolute load problem rather than an exercise category problem.
Jared Powell:
The barbell or the dumbbell doesn't morph into a dangerous object because it's being lifted in a certain direction. It tends to become dangerous when the load overwhelms what the person in front of you can currently tolerate. We can't run away from basic physics here and we should factor this into our rehab planning, obviously. So the clinical skill is dosing exercises sensibly and relative to the human in front of you rather than binarily pronouncing this exercise good or this exercise bad based on nothing more than anecdote or even mood. So in bringing this episode to a close, is the upright row evil? No more than a peanut is. Absolutist claims, always avoid this or never do that or this exercise equals surgery. Don't survive contact with how complex pain and injury are. In this case, the upright row is bad cro- crowd rely on a theory that's near dead and not enough attention is given to the variable which is often the most important, the individual doing the lifting.
Jared Powell:
Okay, that's all for today. Hopefully that's another zombie idea back in the ground. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Terrabalang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
