I find that subacromial pain as it relates to bodybuilders often responds differently (natural history, management) compared to other common overuse injuries such as patellar tendinopathy (hack squats), golfers elbow (straight bar curls), triceps tendinopathy (skullcrushers). With the other common overuse injuries listed above, unless changes are made to exercises, angles, stance, grip, handles, technique, volume, intensity, frequency the pain is generally not going to go away (poor natural history). I will add that I generally prefer to manipulate angles/stance/exercises before volume, intensity, frequency. For example, smith squats are generally much more comfortable on the knees; overhead rope extensions attached to low pulley is generally much more comfortable for the elbows; ez-bar curls are generally much more comfortable for the wrists and elbows.
I find subacromial pain interesting bc it often warms up and desensitizes after a couple sets—at the very least much more so compared to other overuse injuries. It is also often not clear and obviously predictable what angles/exercises provoke the pain. And even when you can pinpoint what angles/exercises provoke the pain, it often leads you scratching your head "Why those specific angles/exercises?" For example, a lifter may report incline barbell presses are most painful but overhead presses and dumbbell laterals feel just fine.
Nonetheless, while the shoulder pain may linger for quite a while (months), it's not unusual that the pain will improve markedly and clear up even if you train right through it. So, in comparison to other insidious onset overuse injuries, I generally have a much higher threshold to meddle with exercises, angles, volume, intensity, frequency. Instead, if pain is tolerable and especially if the pain warms up and desensitizes after a couple sets, I usually have no reservations recommending bodybuilders train through the pain. And I offer reassurance that while it may take a couple months, I anticipate the pain will improve markedly or clear up.
I am confident you are generally not doing any damage to the rotator cuff muscles by training through the pain. Read this:
"Narrative challenges to the subacromial impingement theory have been published,17,19–23 arguing that the anatomy, pathology, poor relationship between imaging and symptoms, and equivalent outcomes obtained with other interventions, such as exercise, even in the presence of a type 3 acromion, compellingly dispute the relevance of the acromion as initially hypothesized.
Lewis17,19,22 also hypothesized that the benefits of the surgery may be due to the potential benefits of a placebo effect. A substantial body of clinical research now suggests that the reported outcomes of many elective orthopaedic surgical procedures may be attributable to such a response.8,10,26,29,30
The findings of the recently published Can Shoulder Arthroscopy Work (CSAW) study1 have substantially confirmed these earlier hypotheses. In this randomized 3-group trial, acromioplasty was reported to be no more beneficial than investigational arthroscopy and no intervention at 6-month and 1-year follow-ups. Although pressured saline would have been introduced into the shoulder in the investigational arthroscopy group, it was designated as a placebo, as no bone or soft tissue was removed. These findings substantially challenge the rationale behind the proposed biomechanical benefit of subacromial decompression surgery and may herald the end of the era for this procedure. At the very minimum, they should challenge surgeons, health funding bodies, insurance providers, clinicians, the media, and those contemplating surgery to reflect on the published literature."
"However, there is a fairly large “elephant in the room” here: if surgery can be a placebo, exercise could be a placebo as well, or both interventions may only be mapping the natural course of the condition as the patient's symptoms regress to the mean."
To extend on the excerpt directly above, and I emphasize the part about favorable natural course of the condition (albeit long course), as long as a lifter is on a well-rounded hypertrophy routine with rows/pulls in different angles, presses/pushes in different angles (including overhead presses), laterals, rear delt flies I generally do not recommend isolated rotator cuff exercises. You can't help but to recruit the rotator cuff muscles if you're on a well rounded hypertrophy routine and I'd argue that isolated cuff work is superfluous for this specific population.
This does not extend to post-ACL reconstruction rehab where leg extensions should be performed. But what I just wrote in the prior sentence also does not extend to what exercises are most effective for quad development—heavy squat variations. That's for another post though.
"Finally, what should we call this condition? Impingement is inappropriate; an aberrant acromion is not pushing down onto the underlying tissues."
This editorial was published in 2018 and they suggested the term "rotator cuff-related shoulder pain." If we are honest about the uncertainty and evidence wrt insidious onset shoulder pain, the most specific we can get is a term like "subacromial pain." We actually can't confidently say the pain is arising from the rotator cuff. And just like "impingement" foments unnecessary fear wrt any type of arm activity above 90 degrees, "rotator cuff related shoulder pain" or "rotator cuff tendinopathy" foments unnecessary fear that there is damage/irritation to the rotator cuff muscles. We actually can't confidently say that. I have no problems saying that anterior knee pain from hack squats is patellar tendinopathy, elbow pain from skullcrushers is triceps tendinopathy, medial elbow pain from straight bar curls is wrist flexor tendinopathy (golfers elbow) because the provoking factors, conditions, and response to interventions are way more straightforward and predictable (e.g. If a lifter experiences a lot of anterior knee pain from hack squats, the pain will often improve markedly with a squat variation where they can kick their hips back slightly such as smith squat, or hack squat with a small foam roller nudged right under the shoulder pads flush against the back pad)—I can't say the same about insidious onset subacromial pain. See below.
