Brief Review

The Contribution of Muscular Fatigue and Shoulder

Biomechanics to Shoulder Injury Incidence During
the Bench Press Exercise: A Narrative Review
Jodi G. Motlagh, and David B. Lipps
School of Kinesiology, University of Michigan, Ann Arbor, Michigan

Abstract
Motlagh, JG and Lipps, DB. The contribution of muscular fatigue and shoulder biomechanics to shoulder injury incidence during the
bench press exercise: A narrative review. J Strength Cond Res 38(12): 2147–2163, 2024—Participation in competitive powerlifting
has rapidly grown over the past two decades. As a result, powerlifting-related injury incidence has likely increased proportionally.
Consistent high-load training places excess strain on the multiple joints involved during the squat, bench press, and deadlift. This
literature review provides a comprehensive overview of all necessary considerations for evaluating the relationship between training
methods, muscular fatigue, shoulder biomechanics, and shoulder injury risk in experienced powerlifters performing the bench
press. Training methods such as velocity-based training, rate of perceived exertion/repetitions in reserve, and autoregulatory
progressive resistance training should be prioritized over the repetitions until failure method to minimize the risk of overexertion.
Despite the high risk of shoulder injury, these findings often lack robust insights into shoulder joint biomechanics during the bench
press. Assessing shoulder joint angles and moments can provide valuable insight into an athlete’s bench press form and technique
to minimize injury risk. With a more robust methodology (e.g., motion capture, ultrasound imaging), alterations in shoulder bio-
mechanics can be assessed during fatiguing training sessions, leading to more generalizable findings on the impact of sex, age,
training experience, and bench press form on the shoulder injury risk. This research will improve individualized programming for
peak powerlifting performance and optimal shoulder injury prevention.
Key Words: resistance training, powerlifting, glenohumeral joint, exercise prescription, overuse injuries

Introduction joint can alter the risk of shoulder injury as an individual pro-
gresses through multiple fatiguing sets of bench press exercises.
Three compound lifts are included in the sport of powerlifting: the
This literature review provides a comprehensive overview of all
squat, deadlift, and bench press (3). Some individuals pursue
necessary considerations for evaluating the relationship between
powerlifting competitively, whereas others may train more rec-
muscular fatigue and shoulder biomechanics in experienced
reationally. However, if proper precautions are not taken, there is
powerlifters (Figure 2). First, common bench press shoulder in-
an inherent risk of injury, as with any other sport. In 1998,
juries will be identified. Next, several methods of adjusting re-
overuse injuries, including tendinopathies, comprised between
sistance training intensity and quantifying muscular fatigue will
3.5 and 12% of all weight-training injuries among the studied
be evaluated. This review will also address methods of quantify-
population (34). Considering potential recall bias and limited
ing and measuring changes in shoulder biomechanics and discuss
subject pools, overuse injury incidence was likely underreported
the generalizability of findings in existing literature concerning
at that time. Between 1998 and 2019, the sport of powerlifting
the bench press exercise. Finally, the implications of evaluating
saw a 1,495% increase in participation at the competitive level
biomechanical changes in the shoulder joint related to bench press
(Figure 1). With such a dramatic uptick in athlete participation,
performance and injury prevention will be addressed. This review
rates of overuse injuries have likely increased proportionally.
aims to inform a research plan to determine how shoulder bio-
When looking at the bench press specifically, Fees et al. (11)
mechanics are affected by muscular fatigue during the bench press
and Reeves et al. (34) identified major mechanisms of injuries,
exercise. A better understanding of this relationship is needed
including using a grip width .1.53 acromial width, high exercise
because overuse injuries are the most common form of bench
dose, repetitive strain, and altered proprioception after an injury.
press injury but are also the most preventable with proactive
These factors, especially high exercise dose and repetitive strain,
interventions.
are thought to contribute to many of the overuse injuries that
occur because of the bench press exercise. However, a gap in the
literature exists when looking at the relationship between mus-
cular fatigue and changes in shoulder joint biomechanics. Thus, Common Bench Press Shoulder Injuries
the primary aim of this narrative review was to examine how
Pectoralis Major Rupture
neuromuscular and biomechanical changes within the shoulder
Pectoralis major rupture is one of the most commonly reported
Address correspondence to David B. Lipps, [email protected]. bench press injuries (2,3,36,45). The bench press consists of 2
Journal of Strength and Conditioning Research 38(12)/2147–2163 distinct portions, known as the initiation and recovery phases. In
ª 2024 National Strength and Conditioning Association the initiation phase, elbows are flexed and shoulders are extended

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 Shoulder Overuse Injuries and Bench Press (2024) 38:12

Figure 1. Growth of competitive powerlifting worldwide between 1986 and 2019

based on open-source competition data from the OpenPowerlifting project (https://
data.openpowerlifting.org).

about the horizontal plane. The pectoralis major contracts con- 25–40% of the weight that it could tolerate in an isometric hold.
centrically as the barbell is pressed off the chest. In the recovery This indicates that a muscle might endure a heavy isometric hold
phase, elbows are extended and shoulders are flexed. An eccentric but will be placed under excess strain while attempting to lift the
contraction of the pectoralis major occurs as the barbell is low- same weight (36).
ered back to the chest (36). The greatest activation of the pec- The pectoralis major contributes to a slow and controlled de-
toralis major occurs during the acceleration phase, as the barbell scent as the individual lowers the barbell to the chest. This works
is initially pushed off the chest. However, it is also important to as a protective mechanism to keep the barbell from falling onto
address the consistent electromyographic (EMG) activation of the the body (2). During a simulated bench press repetition using a
pectoralis major throughout the descent and ascent of the lift (10). human hemithorax specimen, researchers found that shorter
An additional factor to consider includes the isometric and iso- pectoralis major fibers become disproportionately stretched in the
tonic characteristics of muscles. During an active lifting move- final 30 degrees of shoulder extension (45). With each repetition,
ment, an individual muscle can only tolerate approximately the pectoralis major is forced into a mechanically unfavorable

Figure 2. The conceptual framework for this narrative review connects prevalent shoulder injuries (e.g., pectoralis major
rupture, bench pressers’ shoulder, and overuse injuries) during the bench press exercise to altered shoulder biomechanics
during fatiguing sets. The impact of muscular fatigue on shoulder biomechanics is addressed from 2 standpoints: quan-
tifying muscular fatigue and resistance training intensity, and quantifying shoulder biomechanics. The review then considers
how generalizability factors such as training experience, bench press form, sex, and age impact the relationship between
injury and shoulder biomechanics. Information from the review was considered to identify clear knowledge gaps in the
literature, thus prompting future research in this field.

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position toward the end of the eccentric phase. When considering exercises. Details on studies that used objective outcome measures
additional factors such as barbell load and muscular fatigue, in- are provided in Table 1.
dividuals are more likely to experience rupture of the affected
pectoralis major fibers during the eccentric portion of the bench
press (2,36,45).
Methods of Quantifying Muscular Fatigue and Adjusting
Resistance Training Intensity
Bench-Presser’s Shoulder: Insertional Tendinopathy of the Training Until Failure. Training to failure or “repetition failure”
Pectoralis Minor is the process of eliciting progressive fatigue through consecutive
Insertional tendinopathy can affect any tendon within the body and repetitions of an exercise until no more repetitions can be com-
is a common diagnosis among professional and recreational athletes. pleted (8). Training to failure has become a topic of debate among
Specific tendinopathies of the rotator cuff, pectoralis major, and coaches and practitioners involved in resistance training. When
biceps long head contribute to the etiology of shoulder pain. The investigating the impact of this training method in physically
pectoralis minor is a smaller muscle that lies deep to the pectoralis active male subjects with no prior experience in resistance train-
major and is responsible for the anterior tilt of the scapula. Activities ing, training to failure with low loads was beneficial in increasing
such as swimming, push-up, and bench press exercises all elicit this hypertrophic gains and muscular endurance (18,25). Young adult
type of movement (4). During the bench press, an overuse insertional male subjects with over 6 months of strength training experience
tendinopathy of the pectoralis minor muscle was investigated as the saw more significant strength gains in the bench press while
root cause of nontraumatic shoulder pain. This condition is de- training to failure with a moderate load compared with non-
scribed as a “bench-presser’s shoulder” (4). Bench-presser’s shoulder failure training (8). Conversely, training to failure using high
is an insertional tendinopathy of the pectoralis minor. It will clini- loads did not provide additional benefits in untrained, physically
cally present as pain and tenderness of the medial juxta-coracoid active male subjects. High loads used at a lower repetition volume
worsened by contraction of the pectoralis minor, specifically in were required to elicit maximal gains in muscular strength (25).
pressing movements. Factors such as training errors, poor technique, Training to failure results in increased levels of neuromuscular
and a rapid increase in load and frequency during these activities can fatigue and muscle damage lasting up to 48 hours postexercise
contribute to and exacerbate overuse of the pectoralis minor (4). (35). Such levels of neuromuscular fatigue contribute to reduced
strength gains as an athlete progresses through their training
program (19). Neuroendocrine fatigue is also a concern when
Overuse Injuries training to failure, resulting in a change in the concentration of
circulating hormones within the body. This can subsequently
Powerlifters are at risk for sustaining overuse injuries because of
affect the metabolism of an individual, thus impairing muscle
the incredibly high physical demands of performing bench press
recovery (18,25). The main concern surrounding deficits in neu-
exercises, often several times a week. The most prevalent injury
romuscular control is athlete safety. Optimal neuromuscular
sites for powerlifters are the lumbopelvic region, shoulder, and
control aids in the balanced load distribution throughout the
hip (41). The repetitive hyperextension of the shoulder during
joints, minimizing the risk of acute injury (3). The lack of neu-
bench press exercises can place large amounts of stress on the
romuscular control from training to failure introduces a potential
acromioclavicular joint while also causing trauma to the shoulder
implication for injury in athletes who repeatedly train at such high
capsule. These conditions are exacerbated when the elbow of the
levels without proper recovery.
athlete drops below the level of the bench (34). Non-elite pow-
Duffey and Challis (9) took a slightly different approach,
erlifters commonly self-report excessively high training volumes,
investigating the changes in barbell kinematics during a bench
intensities, and poor technique as vital factors contributing to
press set to failure. Their results indicate that the time spent
injury incidence (41). However, this creates a paradox in pow-
pressing the barbell between the first and last repetition in the
erlifting because these factors (e.g., heavy loads and repetitive
set more than doubled, leading to a decrease in mean and peak
training) are readily encouraged. Several athletes will continue to
velocity as the athlete approached the final repetition. Along-
push themselves past their limits despite experiencing pain while
side a reduction in velocity during the pressing movement, the
training, thereby increasing the risk of injury (15). Although re-
path of the barbell in the horizontal plane also changed as the
covering from an overuse injury, training modifications are
individuals neared repetition failure. With increased fatigue,
needed to continue participation, such as reduced training
the barbell was kept more directly over the shoulders during
volume/intensity, changes in technique, and omitting specific
the lift phase of the movement, resulting in a noticeable de-
exercises (41). When modifying technique, however, it is imper-
viation from the ideal straight-line bar path (9). This quanti-
ative that athletes exercise caution and reduce the load of the
fiable deviation in bench press form while approaching failure
barbell. This is especially important because of the altered joint/
helps emphasize the challenges that arise while implementing
soft-tissue proprioception and coactivation of the rotator cuff
the training-to-failure method. Especially in novice lifters,
muscles post-injury. The athlete risks recurrent instability of the
rapid improvements in neural firing patterns occur during the
anterior glenohumeral joint and chronic pain brought on by re-
initial stages of resistance training (9). As a result, it is likely
petitive strain if rehabilitation is not carried out correctly (3,15).
beneficial for novice and intermediate lifters to shift their focus
toward learning proper movement patterns to ensure favorable
long-term training outcomes. However, lifters of all levels must
Understand the Impact of Muscular Fatigue on
be cognizant of the changes in barbell kinematics while train-
Shoulder Biomechanics
ing to failure in the bench press exercise (9). The simultaneous
The following section reviews methods for quantifying muscular increase in time spent pressing the barbell and the deviation in
fatigue, adjusting resistance training intensity, and measuring the barbell path make for an unfavorable training environ-
shoulder biomechanics during the performance of bench press ment, increasing the potential risk of injury.

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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.*
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
Colquhoun et al. (6) (n 5 25) APRE 25 male subjects with at least 6 Random assignment to 1 of 2 Training method 1. Bench press, squat, and 9-wk resistance training After the 9-wk resistance
months of resistance training groups deadlift 1RM protocol training program, significant
experience, training at least 3 increases in the squat, bench
times per wk were included in press, deadlift, and powerlifting
this study. Subjects had to be total were found between both
able to squat 125% body mass, experimental groups. However,
bench press 100% body mass, there were no differences in
and deadlift 150% body mass. psychological factors such as
motivation to train, session RPE,
and satisfaction with the training
session.
1. Flexible daily undulating 2. Body composition To avoid bias, the 3 workout
periodization (n 5 14) days were titled the “green” day,
“red” day, and “blue” day.
These corresponded with the
hypertrophy, power, and
strength days, respectively.
2. Daily undulating periodization 3. Motivation to train Daily undulating periodization:
(n 5 11)
4. Session RPE/satisfaction with Monday: Green day
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training session (hypertrophy, higher repetitions)

Wednesday: Red day (power,
moderate repetitions)
Friday: Blue day (strength, low
repetitions)
Flexible daily undulating
periodization
Freedom to choose the order in
which they complete the 3
workouts throughout the week
Drinkwater et al. (8) (n 5 26) Training until failure 12 junior elite male basketball Random assignment to 1 of 2 Training protocol 1. Bench press 6-wk training program, 3 Larger strength and power gains
players and 14 junior elite male groups sessions per week; loads were were found in the group
soccer players all with determined based on subjects’ completing repetitions to failure
moderate-to-extensive weight- predetermined 6RM during the bench press
training experience (6 mo to 3 exercise.
y).
1. Repetitions to failure (n 5 15) 2. Bench throw Training to failure: 4 sets of 6
repetitions, with 260 s between
sets
2. Repetitions not to failure 3. Fatigue and failure Training not to failure: 8 sets of
(n 5 11) 3 repetitions, with 113 s
between sets
Subjects were pair-matched
using sport, 6RM, and number
of years on an AIS scholarship
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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.* (Continued)
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
Duffey and Challis (9) (n 5 18) Training until failure 10 male and 8 female subjects Subjects were not split into Fatigue 1. Kinematic changes in a set to One laboratory visit As the subject progressed
with no previous participation in groups and instead followed an failure toward volitional failure, there
formal strength training. identical experimental were noticeable changes in
However, all subjects had procedure barbell kinematics.
completed a 14-wk introductory
strength training class at
Pennsylvania State University.
2. Maximal lift kinematics Testing 1RM: First attempt at
85% self-reported 1RM. If
successful, 5% of the self-
reported 1RM is added to the
total load and attempted after a
3-min rest. This continues until
the subject is not able to lift the
load.
Main task: Subjects were
instructed to perform as many
repetitions as possible with a
load equivalent to 75% of their
tested 1RM.
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Helms et al. (16) RPE 21 male subjects with at least 2 Subjects were counterbalanced Method of loading 1. 1RM test 8-wk resistance training It was determined that both the
y of resistance training using their pretest 1RM values during training protocol following a daily 1RM percentage and RPE
experience were included in this and split into 1 of 2 groups: undulated periodization model. loading methods are effective in
study. Subjects were also increasing measures of strength
required to have trained the and hypertrophy. However,
back squat and bench press at authors concluded that the RPE
least 1 time each week for the 6 loading method may provide a
mo before this study. Subjects slight advantage in relation to
must have the ability to back 1RM strength.
squat 1.53 body mass and
bench press 1.253 body mass
for a 1RM.
1. Percentage 1RM (n 5 11) 2. Both groups trained on Monday,
Muscle Wednesday, and Friday and
thickn completed the repetitions in a
ess fixed, descending order
2. RPE (n 5 10) 3. Training RPE, volume, and Percentage group
intensity
4. Perceived readiness Weeks 1 and 8, only 2 sets
completed on each day
Weeks 2–7: 3 sets of 2–8

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repetitions at 70–92.5%
1RM depending on the day
(protocol specified in
paper)
RPE group
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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.* (Continued)
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
Weeks 1 and 8, only 2 sets
completed on each day
Weeks 2–7: 3 sets of 2–8
repetitions at RPE 6–10
depending on the day
(protocol specified in
paper)
Izquierdo et al. (18) (n 5 42) Training until failure 42 Basque ball players Random assignment to 1 of 3 Training protocol 1. Body composition 16-wk periodized training Training to failure was beneficial
volunteered as subjects for this groups program broken up into 3 for improving muscular
study. Subjects had an average separate 5- to 6-wk blocks, 2 endurance, but training not to
of 12.5 y of experience in sessions each week lasting failure was more beneficial for
Basque ball, and also 45–60 min. Loads were increasing strength and power.
participated in strength training. determined based on subjects
predetermined 1, 6, and 10RM
values.
1. Repetitions to failure (n 5 14) 2. Maximal muscle strength and Bench press and squat were
power investigated. The following
values are indicative of the
bench press programming.
2. Repetitions not to failure 3. Hormonal Training to failure:
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(n 5 15) data
3. Control (n 5 13) Block 1: 3 sets of 10RM
Subjects were matched based Block 2: 3 sets of 6RM
on physical characteristics and
muscle strength-power indexes
Block 3: 3 sets of 2–4
repetitions using 85–90%
1RM
Training not to failure:
Block 1: 6 sets of 5
repetitions using 10RM
load
Block 2: 6 sets of 3
repetitions using 6RM load
Block 3: 3 sets of 2–4
repetitions using 85–90%
1RM
Control: continued their normal
training program
Izquierdo-Gabarren et al. (19) Training until failure 43 male rowers with an average Random assignment to 1 of 4 Training protocol 1. Ergometer performance 8-wk linear periodized training The 8-wk linear periodization
(n 5 43) of 12.1 y of regular training and groups: program incorporating strength program that used repetitions
competition experience were and endurance not to failure saw greater
included in this study. Subjects benefits in improving strength,
regularly participated in muscle power, and rowing
traditional rowing, strength performance when compared
training, and athletic training.
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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.* (Continued)
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
with high volume repetitions to
failure.
1. Four exercises leading to 2. Body composition Three resistance training
repetition failure (n 5 14) volumes (sets 3 repetitions)
were used with the same
intensity (10RM to 4RM) among
each of the experimental
groups. However, a different
number of exercises was
assigned depending on the
group (4 exercises vs. 2
exercises).
2. Four exercises not leading to 3. Maximal strength and muscle
failure (n 5 15) power output
3. Two exercises not leading to
failure (n 5 6)
4. Control (n 5 8)
Subjects were matched based
on physical characteristics,
rowing performance, and
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muscle strength-power indexes

Lasevicius et al. (25) (n 5 5) Training until failure 25 physically active male Random assignment of 1 lower Training protocol 1. Maximum dynamic strength 8-wk resistance training Changes in 1RM values were
subjects with no formal limb to 1 of 2 groups test program using different training significantly higher in the 2
resistance/strength training volumes on each of the 2 lower groups that used high-load
experience were recruited for limbs. Training occurred 2 times resistance training. However,
this study. each week on nonconsecutive when focusing on muscle mass
days. and hypertrophy, training with a
high level of effort using low
loads was shown to be
beneficial.
1. High-load resistance training 2. Quadriceps cross-sectional High-load resistance training
leading to failure (n 5 13 limbs) area
2. Low-load resistance training 3. Number of sets, repetitions, Load equal to 80% 1RM
leading to repetition failure and total training volume
(n 5 12 limbs)
The contralateral lower limb was 4. Rating of perceived exertion 3 sets, volume equalized
randomly assigned to 1 of 2 (RPE) scale between experimental
groups groups
1. High-load resistance training Low-load resistance training
not to failure (n 5 13 limbs)
2. Low-load resistance training Load equal to 30% 1RM

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not to failure (n 5 12 limbs)
3 sets, volume equalized
between experimental
groups
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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.* (Continued)
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
Mann et al (27). (n 5 23) APRE 23 Division I collegiate football Random assignment to 1 of 2 Training method 1. Bench press 1RM 6-wk resistance training Over a 6-wk training period,
players, all of whom had groups: protocol APRE was more beneficial than
adequate resistance training linear periodization for
experience. increasing strength in the bench
press and squat exercises.
1. APRE (n 5 12) 2. Squat 1RM APRE, broken down into 3
blocks
2. Linear periodization (n 5 11) 3. Repeated 225-lb bench press 4 sets of the 10RM program
repetitions
4 sets of the 6RM program
4 sets of the 3RM program
Linear periodization:
Week 1: 3 sets of 8 at 70%
1RM
Week 2: 4 sets of 6 at 75%
1RM
Week 3: 4 sets of 5 at 80%
1RM
Week 4: 4 sets of 5 at 82%
1RM
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Week 5: 4 sets of 5 at 85%

1RM
Week 6: Maximal strength
testing
Neto et al. (30) (n 5 21) RPE 21 paralympic powerlifting Subjects were not split into Barbell load and 1. One RM test Three laboratory visits, each The RIR scale was validated for
athletes were included in this groups and instead followed an repetition scheme separated by 48–72 h use in paralympic powerlifting
study. Subjects had to have identical experimental athletes. This allows coaches,
competed in at least 1 national procedure trainers, and athletes to better
level competition and train 3–6 monitor submaximal loads while
times per week. attempting to perfect form and
technique.
2. Maximum repetitions Visit 1
strength test
3. Four-repetitions strength test Standardized warm-up
5 attempts to achieve
maximum load for 1
repetition
Visit 2
Standardized warm-up
Maximum repetitions of 90,
85, 80, and 75% of 1RM
Visit 3:
Standardized warm-up
4 repetitions of 100, 90, 85,
80, and 75% 1RM with a
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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.* (Continued)
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
RIR evaluation following
each set
Ormsbee et al. (31) (n 5 27) RPE 27 physically active college- Subjects were assigned to 1 of 2 Barbell load 1. Rating of perceived exertion One laboratory visit The RIR based RPE scale might
aged male subjects with varying groups based on the inclusion (RPE) and RIR be a beneficial method when
resistance training experience. criteria from the preliminary adjusting training load and
screening questionnaire volume in the bench press
exercise, specifically in college-
aged male subjects.
Group 1: Experienced benchers 2. Average concentric velocity Initial 1RM testing: completed in
(n 5 14) accordance with U.S.
powerlifting guidelines
Resistance training for at Set 1: 1 repetition at 60% 1RM
least 2 y
Bench press training 1 or Set 2: 1 repetition at 75% 1RM
more times each week for
the last 2 y
Test-determined Wilks Set 3: 1 repetition at 90% 1RM
coefficient of at least 70
Group 2: Novice benchers Set 4: 8 repetitions at 70% 1RM
(n 5 13)
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Resistance training for at

least 3 mo but less than 2 y
Bench press training 1 or
more times every 2 wk
Pareja-Blanco et al. (32) Velocity-based training 64 young-adult male subjects Random assignment to 1 of 4 Velocity loss 1. Muscle cross-sectional area 8-wk training program Higher velocity loss thresholds
(n 5 64) with at least 1.5 y of resistance groups: threshold consisting of 2 sessions weekly allowed for greater overall
training experience, specifically with 48–72 h in between resistance training volume
in the bench press, were sessions which encouraged muscle
recruited to take part in this hypertrophy. However, lower
study. During the study, 2 velocity loss thresholds were
subjects discontinued beneficial in promoting positive
participation. neuromuscular adaptations.
Strength gains appeared similar
despite differences in overall
training volume.
1. 0% velocity loss (n 5 15) 2. Isometric test Sessions 1–5: 3 sets at 70%
1RM
2. 15% velocity loss (n 5 16) 3. Progressive loading and Sessions 6–10: 3 sets at 75%
fatigue test 1RM
3. 25% velocity loss (n 5 15) 4. Training program Sessions 11–14: 3 sets at 80%
1RM

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4. 50% velocity loss (n 5 16) Sessions 14–16: 3 sets at 85%
1RM
Relative load was determined
based on individual load-
velocity relationships to ensure
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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.* (Continued)
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
the proper velocity loss was
maintained for each respective
group
Rodiles-Guerrero et al. (37) Velocity-based training 50 young-adult male subjects Using an ABBA Velocity loss 1. Muscle cross-sectional area 8-wk training program To maximize dynamic strength
(n 5 50) with at least 1.5 y of resistance counterbalancing sequence threshold consisting of 2 sessions weekly performance and beneficial
training experience, including based on subjects’ bench press with 48–72 h in between neuromuscular adaptations, a
the bench press, were recruited 1RM, subjects were randomly sessions velocity loss threshold of 25%
to take part in this study assigned to 1 of 4 groups: should be used with a load
intensity between 55 and 70%
1RM. Conversely, higher
velocity loss thresholds would
promote muscle hypertrophy.
1. 0% velocity loss (n 5 12) 2. Isometric test Sessions 1–4: 3 sets at 55%
1RM
2. 15% velocity loss (n 5 13) 3. Progressive loading and Sessions 5–8: 3 sets at 60%
fatigue test 1RM
3. 25% velocity loss (n 5 13) 4. Training program Sessions 9–12: 3 sets at 65%
1RM
4. 50% velocity loss (n 5 12) Sessions 13–16: 3 sets at 70%
1RM
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Relative load was determined

based on individual load-
velocity relationships to ensure
the proper velocity loss was
maintained for each respective
group
Sánchez-Medina and Velocity-based training 18 male firefighters/firefighter Subjects were divided into 2 Resistance exercise 1. Velocity and 8-wk resistance training A strong relationship was found
González-Badillo (38) (n 5 18) candidates with a minimum of 3 groups based on the exercise protocol countermovement jump height program with approximately 21 between the mechanical and
y resistance training experience that was being performed losses exercise sessions metabolic measures of fatigue
were recruited for this study in the postintervention testing,
supporting the validity of velocity
loss in quantifying
neuromuscular fatigue brought
on by resistance training.
Group 1: Bench press (n 5 10) 2. Mechanical measurements of Session 1: Initial test of 1RM and
fatigue full load-velocity relationship
Group 2: Full squat (n 5 8) 3. Blood lactate and ammonia Sessions 2–6: 5 different tests
response of maximal number of
repetitions to failure (12, 10, 8,
6, and 4RM)
Sessions 7–21: 15 different
resistance exercise protocols
differing in the number of
repetitions performed each set
in relation to the predicted
number of repetitions
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Shoulder Overuse Injuries and Bench Press (2024) 38:12

Table 1
Overview of prior literature investigating methods of quantifying muscular fatigue and adjusting resistance training intensity.* (Continued)
Method of quantifying
muscular fatigue/Training Explanatory Measure(s) used to
Author intensity Training experience Experimental group(s) variable quantify results Description of exercise Primary outcomes
Varela-Olalla et al. (43) (n 5 7) Velocity-based training and RPE 7 physically active young-adult Subjects were not split into Barbell load 1. Mean velocity 3 laboratory visits held at the RPE and velocity loss are both
male subjects with at least 1 y of groups and instead followed an same time of day, each useful measures in accurately
resistance training experience identical experimental separated by 72–96 h of rest estimating the percentage of
procedure performed repetitions in relation
to the maximum possible
number of repetitions (%REP)
during the bench press
exercise.
2. Velocity loss A repetition maximum test was
completed at each visit based
on a target mean velocity,
determined using individual
load-velocity profiles:
3. %REP Visit 1: About 1 m·s21
4. RPE Visit 2: About 0.7 m·s21
Visit 3: About 0.5 m·s21
Weakley et al. (44) (n 5 18) Velocity-based training 18 male and female subjects Subjects were not split into Barbell load 1. Change in velocity using the 5 total testing sessions; The mean concentric velocity
with at least 2 y of resistance groups and instead followed an FLEX device however, the subjects were only outputs provided by the
training experience in the squat identical experimental required to be present for 3 GymAware FLEX device are both
and bench press procedure laboratory visits separated by 72 valid and reliable. This makes it
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h so that the FLEX device can be

used in the prescription of
resistance training to more
accurately monitor athlete
exertion.
2. Change in velocity used Visit 1: 1RM barbell back squat
marker-based motion capture and bench press
Visit 2:
3 repetitions with 20, 40, 60,
and 80% 1RM
2 repetitions with 90% 1RM
1 repetition with 100% 1RM
Visit 3: 6 sets of 3–5 repetitions
with self-selected loads

*RPE 5 rate of perceived exertion; RIR 5 repetitions in reserve; RM 5 repetition maximum.

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 Shoulder Overuse Injuries and Bench Press (2024) 38:12

Velocity-Based Training. Velocity-based training uses barbell have completed at the end of a set (31). From a practical stand-
velocity as an objective measure to inform and improve resistance point, using RIR with RPE allows for greater confidence in athlete
training performance. Across numerous disciplines within re- expression of training difficulty. In a previous study, athletes were
sistance training, quantifying the amount of effort the athlete to estimate an RIR value in addition to a traditional 1–10 RPE
produces primarily depends on subjective measures. The athlete value after a set of resistance training. Despite reaching volitional
and coach are often forced to decide on training difficulty based failure, subjects would incorrectly express submaximal RPE val-
on performance estimation models and the overall “feel” of ues (31). Thus, the combined RPE/RIR scale benefits athletes with
previous repetitions. New paradigms in training now recommend a more appreciable measure of exertion. Ormsbee et al. (31)
focusing on changes in movement velocity throughout a bout of demonstrated the effectiveness of the rate of perceived exertion/
resistance training (13). In the last decade, several studies exam- RIR scale during the bench press exercise to individualize training
ined the implications of movement velocity tracking on resistance sessions better and ensure that physiological stress levels are ap-
training methodology (14). Researchers quantified athlete fatigue propriate for the athlete. In a later study completed by Neto et al.
and exertion by observing real-time decreases in movement ve- (30), the repetition in the reserve scale was validated as a moni-
locity between repetitions of a given exercise. A large association toring tool for submaximal training in paralympic powerlifters,
was found between mechanical and metabolic factors of fatigue, thus increasing generalizability among the powerlifting
thus emphasizing the importance of velocity loss in monitoring population.
neuromuscular fatigue during a bout of resistance training Over an 8-week training period, Helms et al. (16) sought to
(14,38). The training implications of velocity-based training on investigate how rate of perceived exertion and percentage of 1RM
fatigue and injury risk need to be kept in mind given the more load prescriptions differ in relation to strength and hypertrophy
readily available velocity-tracking technologies manufactured for gains. Both loading methods were effective; however, using the
commercial and personal use, including linear transducers, 3- rate of perceived exertion scale would likely provide a slight ad-
dimensional motion capture, and optic laser devices (FLEX vantage in 1RM strength gains (16). In addition, Varela-Olalla
devices). et al. (43) conducted a study using the Borg category ratio 10-
An interesting component of velocity-based training is the ve- point scale to assess if a relationship existed between % repeti-
locity loss threshold during an exercise bout. Overall velocity loss tions (repetitions completed about the maximum number that
can be calculated using the difference in velocity between the could have been completed), rate of perceived exertion, and ve-
fastest and final repetitions in the first programmed set. Coaches locity loss. The actual and predicted % repetition values were
and athletes can then use this value to determine a velocity loss almost perfectly correlated with the rate of perceived exertion and
threshold that best suits the intended training difficulty. Pareja- velocity loss.
Blanco et al. (32) and Rodiles-Guerrero et al. (37) used a similar
methodology to assess the relationship between velocity loss Autoregulatory Progressive Resistance Exercise. Periodization in
thresholds of 0% (low), 15%, 25% (moderate), and 50% (high) exercise programming explains the manipulation of several
during the bench press exercise and factors such as muscle training variables (i.e., training volume, required rest, intensity of
strength, hypertrophy, and neuromuscular adaptations. Using a training, and more) throughout a training cycle of some specific
high-velocity loss threshold (25–50%) with moderate load in- length. Linear periodization, otherwise described as the pro-
tensities (55–70% one repetition maximum [1RM]) allows for gressive increase of intensity and simultaneous decrease in volume
greater volume in repetitions and momentary muscular fatigue is throughout a training cycle, is a classic form of periodization (27).
maximized, leading to hypertrophic gains (32). By contrast, re- However, this does not allow for proper athlete autonomy or
sults from the study conducted by Rodiles-Guerrero et al. (37) training preparedness/recovery variations. “Autoregulation” of
depicted unfavorable neuromuscular adaptations in relation to training is far less common than linear periodization, and limited
strength gains while using a velocity loss threshold of 50% with literature examines the potential benefits. Autoregulation peri-
similar load intensities. If the goal is to maximize strength gains, odization is a unique form of training that allows for changes in
moderate velocity loss thresholds (,25%) can prevent excessive the well-being and recovery of the athlete on a day-to-day or
neuromuscular fatigue (32,37). Pareja-Blanco et al. (32) de- week-to-week basis. Although highly variable, autoregulation
termined that the peak EMG signal of the pectoralis major, one of training allows athletes to gain strength while working at their
the prime movers during the bench press exercise, occurred at a own pace and allowing for unexpected rough patches (27). In a
velocity loss threshold of 15%. Overall, particular care must be study conducted by Mann et al. (27), Division I college football
taken when using velocity-based training as a primary training players increased their strength more effectively in the squat and
method, depending on the goal of the individual athlete. bench press exercise throughout 6 weeks using autoregulation
periodization instead of linear periodization, providing strong
Rating of Perceived Exertion/Repetitions in Reserve. Rate of evidence for using autoregulation for experienced athletes.
perceived exertion, or RPE, is an athlete feedback model used to Conversely, a study investigating autoregulatory resistance
adjust load progression based on individual needs and assess- training on moderately experienced powerlifters found no sig-
ments, a stark difference from the traditional linear/fixed pro- nificant differences in strength gains, training motivation, and
gression model. There are 2 common rates of perceived exertion training satisfaction after a 9-week protocol comparing autor-
scales: Borg 15-point and Borg category ratio 10-point scale (31). egulation and linear periodization (6). However, preliminary
Originally, rate of perceived exertion scales were primarily used findings demonstrated slight increases in program adherence and
to gauge perceived exertion during aerobic training efforts. overall attendance while using the autoregulatory training
However, Ormsbee et al. (31) adapted an existing rate of per- method. As a result, there may be positive associations between
ceived exertion scale to create a more suitable scale for resistance autoregulation and training adherence, strength gains, and ath-
training, in which perceived exertion is compared with a repeti- lete motivation over more extended periods (6). It would be
tion in reserve (RIR) value. Repetition in reserve addresses the beneficial to conduct further research on the impact of autor-
number of additional repetitions an individual feels they could egulatory progressive resistance exercise (APRE) across sports

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 Shoulder Overuse Injuries and Bench Press (2024) 38:12 | www.nsca.com

and disciplines to determine if certain athletes respond better to the nipple line to reduce the moment arm about the shoulder joint
this training form than others. while also minimizing shoulder abduction (,90°) and external
Current APRE models include 3 different loading patterns that rotation. By making these changes, individuals can maintain
use percentages of an athlete’s 10RM, 6RM, and 3RM for a performance and reduce the risk of shoulder injury (22). Overall,
certain number of repetitions (42). The 10RM model is geared this study highlights the importance of tracking joint angles with
toward developing hypertrophy; the 6RM model targets both other physiological signals to clarify the underlying muscular
hypertrophy and strength, and the 3RM model targets strength response to bench press exercises. Future research should focus on
development. Autoregulatory progressive resistance exercise in- changes in joint angles brought on by factors other than barbell
cludes 4 total sets in the program, regardless of the training model load and grip width, allowing for a more comprehensive un-
chosen. The first 3 sets have a set volume and intensity that the derstanding of the movement.
athlete must follow; the load used in the fourth set is adjusted
based on athlete performance during the third set. The final 2 sets Joint Moments (Kinetics). The study of kinetics primarily focuses
encourage lifting to failure, which can result in increased mus- on how force acting upon an object can cause changes in move-
cular fatigue (42). Thus, extra precautions must be taken with this ment. Kinetics can become a significant factor in resistance
training method to prevent injuries caused by overuse and mus- training when aspects such as injury risk, movement efficiency,
cular fatigue. and athletic performance are questioned. The force-length re-
lationship becomes increasingly crucial while attempting to
maximize muscular strength and athletic performance. Moving a
muscle into certain positions can negatively affect the force-length
Quantification of Shoulder Biomechanics
relationship, resulting in a region of poor mechanical force out-
Joint Angles. Tracking bench press kinematics is important to put, also known as the “sticking region.” This suboptimal output
ensure proper form and mitigate the risk of potential injury. may cause lift failure, which can be dangerous if proper precau-
However, few studies have examined potential changes in tions are not taken to minimize the risk of injury (24).
shoulder joint kinematics during the bench press exercise. A re- Using marker-based motion capture and an in-ground force
cent study by Larsen et al. (24) used a comprehensive approach to plate, Larsen et al. (24) investigated the forces acting on the
measure shoulder joint kinematics while subjects completed the shoulder and elbow joints during the bench press exercise among
bench press using a wide, medium, and narrow grip width. Re- subjects using varying grip widths. Joint angles and force plate
flective markers were placed on the barbell and the shoulder, measurements were used to isolate single-joint moments
elbow, and wrist. With marker-based motion capture software, throughout each phase of the bench press exercise (24). A wide,
researchers determined shoulder flexion or abduction and elbow medium, and narrow grip during the bench press resulted in
extension by calculating angles between body segments (24). medially-directed, vertically-directed, and laterally-directed re-
Across 4 time points during the bench press, shoulder abduction sultant forces, respectively. With an interest in the sticking region
and elbow extension angles increased significantly, whereas during a 1RM bench press attempt, Larsen et al. (24) concluded
shoulder flexion angles decreased significantly. Subjects generally that using a wide or medium grip would be more biomechanically
experienced larger shoulder abduction, shoulder flexion, and el- advantageous if the goal is to successfully lift a maximum attempt.
bow extension angles when using a wide grip as opposed to a With a similar interest in the sticking region, Elliott et al. (10)
medium or narrow grip. As a result, moment arms about the analyzed shoulder joint kinetics during the ascent phase of the
shoulder joint were greatest when using a wide grip across all time bench press exercise using an alternative method. Using the dis-
points (24). The peak shoulder moment arm using a wide grip tance between the wrist and shoulder joint in the transverse and
occurred at the start of upward movement during the bench press, sagittal planes, barbell line of action, and 3-dimensional vertical
considered a vulnerable position for the shoulder joint (24,34). displacement data, the authors derived resultant moment arms
Taking these factors into account, caution should be exercised corresponding to 3 stages of the barbell ascent (10). These data
when completing a wide-grip bench press to avoid undue stress on demonstrated an increase in the resultant moment arm during the
the shoulder joint resulting from greater abduction and reduced concentric phase of the lift. However, this increase did not con-
flexion. tribute to the sticking region phenomenon. As a result, Elliott
Other factors beyond grip width may alter shoulder joint ki- et al. (10) postulated that the sticking region occurs because of a
nematics during bench press exercises. Król and Golaś (22) were mechanically poor force-production position, in addition to the
interested in understanding the role of barbell weight on the rapid dissipation of strain energy.
structure of the flat bench press. Recreationally trained male Another study completed by Cudlip et al. (7) introduced yet
subjects were instructed to complete a specific bench press pro- another method of joint moment calculation. Using motion cap-
tocol at approximately 70, 80, 90, and 100% of their 1RM, and ture data and inverse dynamics, researchers determined how
changes in movement characteristics were assessed using a multi- standard and powerlifting bench press techniques alter shoulder
modular measuring system (22). This study examined the asso- joint loading (7). An arched powerlifting technique resulted in the
ciation between changes in joint angle and muscle activity pat- minimal horizontal displacement of the barbell relative to the
terns rather than how joint angle patterns affect performance and shoulder, thus decreasing the shoulder moment arm throughout
injury risk. Barbell load played an important role in the resulting all phases of the lift. This arched powerlifting technique could be
joint angles and muscle activity patterns. As the barbell load in- favorable over the standard technique because of the ability to
creased, the role of several muscles involved was seemingly re- increase activation of the latissimus dorsi during the sticking re-
versed to better balance and stabilize the barbell throughout the gion while avoiding excess loading upon the shoulder joint (7).
lift. For example, the pectoralis major shifted from a prime mover Together, these studies demonstrate the existence of previous
to a supportive role, whereas the deltoid and triceps brachii be- literature examining joint kinetics during various phases of the
came the prime movers (22). Taking this into account, it was bench press exercise. Data on shoulder joint loading during the
recommended that individuals focus on lowering the barbell to bench press can be beneficial when analyzed alongside shoulder

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 Shoulder Overuse Injuries and Bench Press (2024) 38:12

joint angles. When used in conjunction, inferences regarding in- measurements and joint angle calculations. Several studies in-
jury prevention and ideal bench press form can be made. vestigating the bench press exercise have incorporated marker-
based motion capture to track the movement of the barbell, the
Joint Imaging. Ultrasound imaging allows for convenient mea- subject, or both. In a study by Weakley et al. (44), marker-based
surement of the subacromial space and supraspinatus tendon—2 motion capture was used to validate the efficacy of a novel optic
factors involved in shoulder biomechanics that are not often laser device (FLEX device) in determining barbell velocity and
studied in relation to resistance training. A thicker supraspinatus displacement. When used in conjunction with motion capture, it
tendon may contribute to subacromial impingement syndrome was found that the FLEX device provided valid and reliable ve-
because of a larger occupation ratio (29). The occupation ratio is locity measurements across various movements. Thus, coaches
operationally defined and calculated as the ratio of supraspinatus and athletes can confidently incorporate this device in velocity-
tendon thickness to acromiohumeral distance (29). As a greater based training to monitor levels of progressive fatigue (44).
occupation ratio may play a part in subacromial impingement Using marker-based motion capture in a different context,
syndrome, it is important to understand how resistance training, Duffey and Challis (9) examined the effect of fatigue on barbell
including the bench press, may affect the subacromial space and kinematics during the bench press. Reflective markers were
supraspinatus tendon. Despite the largely unknown nature of placed on the barbell and the subject to track the barbell position
tendon vascularity, Bordoni et al. (5) determined that an increase about the shoulder, and it was found that bar kinematics change
in mechanical stress and loading of the tendon will consequently dramatically with increased fatigue during a set. However, it is
increase blood flow to the tendon. Future research should con- important to note that this study focused more on the differences
sider implementing ultrasound imaging to study resistance in barbell motion throughout a bench press set to failure than
training exercises, including the bench press, to better understand differences in subject movement (9). Larsen et al. (24) used a
the potential mechanisms behind chronic injury development. similar approach, placing reflective markers on both the barbell
Subacromial impingement syndrome is a prevalent ailment of and the subject to investigate the impact of grip width on kinetics
the shoulder, often characterized by pain experienced between 60 and kinematics during the bench press. Significant differences in
and 120 degrees of shoulder abduction (33). However, there is shoulder abduction, shoulder flexion, and elbow extension angles
poor agreement on the pathological mechanism(s) contributing to were found across the 3 grip widths throughout the course of the
subacromial impingement. Michener et al. (29) conducted a study lift (24). These kinematic findings are imperative in determining
primarily using ultrasound to quantify supraspinatus tendon joint moments during the bench press while also providing
thickness and size of the subacromial space. The study examined valuable insight into biomechanically unfavorable joint posi-
whether an association existed between tendon thickness and tioning that may increase the risk of injury.
subacromial space measurements in subjects with impingement Although marker-based motion capture is widely used and
syndrome compared with healthy controls. The supraspinatus accepted, reflective markers on the body can become a distraction
tendon was measured in the short (transverse) axis with the and potentially alter performance during the bench press exercise.
transducer placed on the anterior portion of the shoulder. The To fully capture the shoulder girdle for proper kinematic analysis,
subacromial space was measured along the long axis with the it is recommended to place reflective markers on the neck and
transducer placed on the most anterior portion of the acromion back along with the shoulder and arm. When the subject lays
(29). The results demonstrated a thicker supraspinatus tendon down for the bench press, the cameras do not recognize markers
and a greater portion of the subacromial space occupied by the on the back side of the body. As a result, markerless motion
tendon in those with subacromial impingement syndrome. With a capture may be better suited for active motion analysis. Mar-
greater occupation ratio of the subacromial space, these individ- kerless motion capture uses calibrated video data collected from
uals may be more prone to impingement during activities in- multiple cameras and machine learning algorithms to reconstruct
volving arm elevation and shoulder abduction (29). These segment and joint angles. There is no previous literature where
findings are valuable and can be implemented in future research markerless motion capture has been used to analyze the bench
investigating impingement mechanisms during athletic activities press exercise. However, Fleisig et al. (12) and Lahkar et al. (23)
involving the upper limbs. have examined kinematics using both marker-based and mar-
Similarly, Kim et al. (21) used ultrasound imaging to better kerless motion capture in baseball pitching and boxing, re-
understand the dimensions of the rotator cuff complex in healthy spectively. Similar kinematic patterns were found when
Korean adults. Compared with the protocol by Michener et al. examining baseball pitching between the 2 types of motion cap-
(29), the subacromial space was not a structure of interest in this ture technology (12). The study observing boxing kinematics
study. However, the thickness of the supraspinatus tendon was found greater similarity between marker-based and markerless
imaged in a similar manner. Supraspinatus tendon thickness in- motion capture when looking at segment velocities instead of
creased with age and was also greater in male than female subjects joint angles (23). Even so, the practicality and validity of the
(21). However, this study has limited generalizability in that only markerless system were deemed promising, especially in the field
healthy subjects were recruited, and the results only represent 1 of complex sports performance.
cultural population. Future research should investigate the impact
of age and sex on supraspinatus tendon thickness in those with
subacromial impingement syndrome to determine whether the Generalizability
patterns found by Kim et al. (21) and Michener et al. (29) remain
Training Experience
similar.
General resistance training and the sport of powerlifting are
Motion Capture. Marker-based motion capture is currently ac- suitable for individuals with a wide variety of training experi-
cepted as the “gold standard” in motion analysis technology. ences. Powerlifting is a rapidly growing sport, allowing for
Although marker-based motion capture can only be used in lab- competitions at the beginner/novice level, intermediate level, and
oratory settings, it provides the most accurate kinematic sub-elite/elite levels. With more experience, those participating in

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 Shoulder Overuse Injuries and Bench Press (2024) 38:12 | www.nsca.com

the bench press exercise will inevitably modify their form to suit individuals continue to use this technique where the buttocks
their training habits, personal strengths, and overall goals. break contact with the bench, all lifters in present-day power-
Powerlifters have a shorter joint range of motion throughout lifting competitions require the 3-point contact described in
the exercise than recreational lifters and experience lower peak Cudlip et al. (7).
elbow net joint moments (28). This suggests that powerlifters are Grip width on the barbell is another highly variable factor
more shoulder dominant while completing the lift, potentially among individuals who bench press regularly. Previous research
because of the adaptation of nontraditional bench press technique has found that using a grip width greater than 1.53 bi-acromial
to enhance their maximal lift capability (7,28). Future research is width (space between the 2 shoulders) places the individual at a
warranted to understand how these differences between bench higher risk of sustaining a shoulder injury (3,15). Even so, several
press forms vary with powerlifting expertise. powerlifters continue to use wider grips during the bench press
Expert powerlifters competing at a national or world-class exercise to decrease the overall range of motion, thus moving
level maintain more control over the barbell upon initial de- greater amounts of weight with less effort (24,26,28). Although
scent, initiated and ended the movement with the barbell closer grip width is a heavily discussed topic regarding bench press
to the chest, and used a bar path closer to the shoulders (26). performance, there is no consensus on the optimal grip width
These expert powerlifters likely used a wider grip on the barbell placement. According to Green and Comfort (15), a grip width
at the start and end of the bench press with the barbell closer to less than or equal to 1.53 bi-acromial width does not decrease
the chest compared with the novice group (26). However, this overall muscle recruitment and only affects the 1RM by 6 5%
wider grip can potentially lead to upper extremity injury if not while reducing the risk of shoulder injury.
executed correctly (15). Associations between expertise and
injury prevalence must be investigated to determine if and how
training load management and technique optimization are used Sex
to mitigate the risk of injury, especially among elite power-
Until recently, societal standards often pushed the idea that re-
lifters (41).
sistance training was more appropriate for male than female
subjects. As more individuals realize that resistance training is not
Bench Press Form (Grip Width, Arch) sex-specific, the demographic found within the community has
changed dramatically. However, most powerlifting literature
Bench press form is highly variable among individuals and entire
only includes male subjects, thus limiting generalizability to the
populations, with notable differences between traditional and
greater population (28,40,41).
powerlifting-specific techniques. The traditional technique has
Sex has a major impact on overall bench press technique. Fe-
been established by the National Strength and Conditioning As-
male subjects keep their elbows further away from their bodies
sociation, requiring the body to have 5 points of contact with the
throughout the lift, resulting in greater muscular loads in the el-
bench (head, neck, shoulders, lower back, and buttocks). Con-
bow and lesser muscular loads in the shoulder than male subjects
versely, the technique used by powerlifters encourages a greater
(28). With these findings, it is expected that female subjects ex-
arch in the back, resulting in 3 points of contact with the bench
perience greater triceps brachii adaptations than the pectoralis
(head, shoulders, buttocks) (7). In a study of individuals with
major. This differs from male subjects, where increased pectoralis
extensive bench press experience, Cudlip et al. (7) determined that
major adaptations and increased shoulder loading resulting from
the powerlifting or “arch” technique decreased loading of the
the bench press movement are expected (28).
shoulders and increased activation of the latissimus dorsi during
The overall injury frequency is similar among male and female
the bench press exercise. Therefore, it is recommended that
powerlifters. Both sexes report injuries in the lumbopelvic region,
trainers and coaches incorporate the arch technique into bench
shoulder, and hip. However, female subjects reported a greater
press rehabilitation programs, avoiding shoulder loading while
incidence of injuries in the neck and thoracic region compared
encouraging high muscular activation.
with their male counterparts (41). Even though female subjects
However, these results disagree with the findings from Mau-
tend to experience decreased muscular loading in the shoulders
sehund and Krosshaug (28) and Algra (1), which emphasize
(28), keeping the elbows further from the body could potentially
greater shoulder loading among individuals who use the arched
place the shoulders in a biomechanically unfavorable position.
technique. Mausehund and Krosshaug (28) examined net joint
More research is needed to determine if these differences in
moments, moment arms, and muscle activity during the bench
muscular activation and joint movement patterns in female sub-
press, looking at differences between experienced powerlifters
jects could negatively affect performance and injury risk. Future
and recreational lifters and between sexes. Results demonstrated
research should also address differences in bench press form be-
that experienced powerlifters used a unique bar path throughout
tween sexes to determine whether this might affect the increased
the lift, thus affecting joint kinematics. It was deduced that
thoracic/neck region injuries in female subjects.
powerlifters were more shoulder-dominant during the bench
press exercise in comparison with recreational lifters, which
contradicts the results found by Cudlip et al. (7).
Age
Algra (1) identifies “arching of the back” as one of the most
common, yet incorrect, bench press techniques. However, it is Resistance training is nondiscriminatory regarding the age of an
important to note that the definition of the “arch” technique individual who wants to participate. However, previous research
differs between this study and subsequent works discussed above. has found that individuals over 40 years had a higher risk of
As Algra (1) described, the arch technique occurs when the lifter injury while participating in some form of weight training
arches their back by raising their buttocks off the bench during the (34,39,41). According to Reeves et al. (34) and Siewe et al. (39),
pressing movement. With only 2 points of contact on the bench injuries to the upper extremity were much more prevalent in those
(head, shoulders), completing the bench press in this manner will aged 40 years and older when compared with younger individ-
place extreme stress on the mid to lower back (1). Although some uals. This may have to do with the physiological changes and

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 Shoulder Overuse Injuries and Bench Press (2024) 38:12

decrease in joint mobility that takes place during the aging pro-
cess. However, Keogh et al. (20) found no significant differences track muscle fatigue and adjust resistance training intensity,
in powerlifting injury epidemiology between younger and older various models have been used, such as training to failure,
individuals. These discrepancies prompt a need for further re- velocity-based training, rate of perceived exertion, and APRE.
search on the relationship between age and powerlifting injury Training to failure with low loads can promote muscle growth
incidence. and endurance in untrained individuals, but heavier loads may
lead to loss of control, impaired recovery, and increased injury
risk. As fatigue increases, bench press form and technique can
Implications of Fatigue in Bench Press Performance break down, leading to an increased risk of injury. For pow-
and Injury Prevention erlifters, a training model that provides real-time feedback and
Research on the value of combatting overuse/fatigue-based re- bodily autonomy should be favored. Velocity-based training is
useful for monitoring neuromuscular fatigue and providing
sistance training injury is minimal. Completing bench press rep-
constructive feedback. Similarly, the rate of perceived exertion
etitions to failure results in notable changes to the overall lifting
kinematics in recreational lifters (9). It is known that the force and and APRE models are beneficial for promoting athlete au-
tonomy and considering both physical and emotional fatigue.
moment acting on the elbow joint increase when an individual
One limitation of the APRE method is that the final 2 of 6 total
reaches a point of fatigue during the bench press (17). Using the
results from Larsen et al. (24), it is clear that grip width changes sets encourage lifting to failure, which can lead to excessive
fatigue and potential issues for the athlete if not managed
significantly affect the moments and joint angles of the upper
properly. Shoulder biomechanics in the bench press can be
extremities. However, it is unknown whether muscular fatigue
improved by minimizing the shoulder joint moment through
can cause large enough changes in the intrinsic biomechanics of
proper grip width and bar lowering. When modifying the
an individual to warrant subsequent changes in joint angles and
technique, athletes and coaches should consider the risk of
moments, especially in experienced lifters. According to Huang
injury versus force production. The arched powerlifting bench
et al. (17), as an individual fatigues during the bench press, the
increased loading on the elbow can increase the risk of injury to press technique can reduce the shoulder moment arm and
injury risk. Joint imaging and motion capture technology
the entire upper extremity. As a result, it is imperative that one
should be more readily used to assess shoulder injury risk
closely monitors muscular fatigue to enhance bench press per-
formance and prevent unnecessary injury. during the bench press. Ultrasound imaging helps examine the
subacromial space and supraspinatus tendon. People with a
Duffey and Challis (9) recommend that recreational and novice
thicker supraspinatus tendon may be more prone to sub-
lifters emphasize proper bench press form and technique instead
of maximal lifting to enhance bench press performance. Espe- acromial impingement syndrome, but more research on ath-
letic populations is needed. Marker-based and markerless
cially in the early stages of training, lifters experience neural
motion capture techniques can show dynamic movement
changes subject to a certain amount of plasticity (9). These neural
during the bench press, with markerless capture being ideal for
changes must be used to the lifter’s advantage, ensuring bad
habits are not formed in the long run. The athlete or coach should this exercise because athletes can complete exercises in a more
natural environment. The review’s applicability depends on
also control a maximal number of repetitions when programming
training experience, bench press form, sex, and age. Different
to ensure that fatigue is not maximized, especially with the barbell
bench (17). Because the shoulder is a relatively understudied body techniques may be used based on expertise and goals. A wider
grip can reduce the range of motion but should not exceed 1.5
part regarding the bench press, it would be beneficial to conduct
times the bi-acromial width to minimize shoulder injury. Al-
future research examining the direct impact of muscular fatigue
on shoulder kinematics to determine additional injury prevention though injury frequency is similar, female subjects report
more neck and thoracic injuries. Further exploration of the
measures.
impact of physical and physiological differences between male
and female subjects is needed. Finally, individuals aged 40
Practical Applications years and older may face a higher injury risk, prompting a
need for more research on age and powerlifting injury
The primary goal of this review was to aid future research to incidence.
determine how shoulder biomechanics are impacted by mus-
cular fatigue during the bench press exercise. Topics of interest
included common bench press injuries, methods of adjusting Acknowledgments
training intensity, methods of quantifying muscular fatigue
J. G. Motlagh wrote the initial draft of the manuscript. J. G.
and shoulder biomechanics, generalizability of existing find-
ings regarding the bench press, and implications of evaluating Motlagh and D. B. Lipps revised the manuscript. All authors
reviewed and approved of the final manuscript submitted for
biomechanical changes in the shoulder joint during the bench
publication. No funding was received to assist with the
press. Pectoralis major rupture, bench presser’s shoulder, and
overuse injuries are the most discussed ailments in relation to preparation of this manuscript, and the author(s) have no
conflicts of interest to disclose. This manuscript uses data in
the bench press exercise. These injuries largely resulted from
Figure 1 from the OpenPowerlifting project, https://www.open-
training errors, poor technique, rapid increases in load and
training frequency, and repetitive joint strain. Repetitive powerlifting.org. You may download a copy of the open-source
data at https://data.openpowerlifting.org.
shoulder extension during the eccentric portion of the bench
press exercise can place excess stress on the shoulder joint,
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