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4. For some good reading - particularly with respect to nutrition - check out Brian St. Pierre's blog. 5. I'm going with Joseph Addai over LenDale White this weekend.  Thanks to everyone for the feedback from Tuesday.  Fingers crossed... 6. Happy Birthday to Cassandra Forsythe-Pribanic!  Cass and I go way back, and she's been a great friend and resource for me all along the way.  If you're looking for top-notch female-specific nutrition and fitness resources, you definitely ought to check out The New Rules of Lifting for Women and the Women's Health Perfect Body Diet, both of which Cass or co-authored.

I received this email earlier this week: Eric, I am a longtime follower of T-Nation and picked up your book, Maximum Strength, this past summer. I just finished with Moving Day and want to thank you for my great results in 16 weeks.

I am 6'3", 180 lbs and my weight stayed the same the whole time because I have low body fat to begin.

My Results:

Broad Jump: 91" to 122"

Squat: 225 to 295

Bench: 215 to 235

Deadlift: 365 to 455

Chinup 3RM: 45 to 60

This book worked great when I had a goal to strive for. Thanks again, Eric.

Matthew Misiewicz

Baltimore, MD

I won 105-50 this week to move to 8-5 and second my spot as the third seed in the playoffs.  For the record, I was the high scorer in the league, too.  How you like them apples?  Poor Tony was the second highest scorer and didn't even make the playoffs!

In Part I, I went into some detail on why I really didn’t like the catch-all term “shoulder impingement.” This week, I’m going to talk about the different kinds of shoulder impingement: external and internal.

External impingement, also known as outlet impingement, is the one we hear about the most. Here, we’re dealing with compression of the rotator cuff – usually the supraspinatus, and over time, the infraspinatus (and biceps tendon) – by the undersurface of the acromion. This impingement can lead to bursal-sided rotator cuff tears - and happens a lot more with ordinary weekend warriors and very common in lifters (not to mention much more prevalent in older populations.

External impingement can be further subdivided into primary and secondary classifications. In primary impingement, the cause is related to the acromion – either due to bone spurring or congenital shape. As you can see in the photo below, hook (II) and beak (III) are worst than flat (I), as there are marked difference in “clearance” under the acromion.

Secondary impingement, on the other hand, is usually related to poor scapular stability (related to both tightness and weakness, as described in last week’s newsletter), which alters the position of the scapula. In both cases, pain is at the front and/or side of the shoulder and is irritated with overhead activity, scapular protraction, and several other activities (depending on the severity of the tissue problems). You’ll also generally see a lack of external rotation range-of-motion, as these are folks who do too much bench pressing and computer work (both of which shorten the internal rotators).

Conversely, internal impingement, also known as posterosuperior impingement, really wasn’t proposed until the early 1990s. This form of impingement is more common in younger individuals who are involved in overhead sports, making it more of an “athletic impingement.” Adaptive shortening and scarring of the posterior rotator cuff in these athletes causes a loss of internal rotation and an upward translation of the humeral head during the late cocking phase of throwing (or swimming): external rotation and abduction.  These issues are magnified by poor scapular control, insufficient thoracic rotation, and weakness of the rotator cuff.

When the humeral head translates superiorly excessively in this position, it impinges on the posterior labrum and glenoid (socket), irritating the rotator cuff and biceps tendon along the way. So, pain usually starts in the back of the shoulder, as you are seeing irritation of the posterior fibers of the supraspinatus and anterior fibers of the infraspinatus tendons. Gradually, this pain may “shift” toward the front as the biceps tendon, and that implies labral involvement.  At least initially, the pain is purely mechanical in nature; it won't bother an athlete unless the "apprehension" position (full external rotation at 90 degrees of abduction) is created.

We often hear about SLAP lesions in the news. This refers to a superior labrum, anterior-posterior injury. In reality, when we are talking about labral injuries in overhead athletes as they relate to internal impingement, it’s mostly just posterior (although serious cases can eventually affect the anterior labrum, too). There are different kinds of SLAP lesions (1-4). Every baseball pitcher you’ll meet has a SLAP 1, which is just fraying. SLAP 2 lesions are far more serious and often require surgical intervention. SLAP 1 issues become SLAP 2 lesions when poor mobility and dynamic stability aren't established.

So, just to bring you up to speed, we’ve got two different kinds of impingement, one of which (external) has two subcategories that mandate different treatment strategies (primary = surgery, secondary = corrective exercise). We also have two separate areas where pain presents (external = front/side, internal = back). That’s just the tip of the iceberg, though, as we have two more considerations…

First, symptomatic internal impingement tends to be "mechanical pain." Unless you’re dealing with a more advanced case, athletes with symptomatic internal impingement only have pain when they get into the late cocking phase (and sometimes follow-through). It usually isn’t present when they’re just sitting around – and for this reason, they can usually be more aggressive in the weight room with upper body training. Keep in mind that I use the term “symptomatic” because I think that internal impingement is a physiological norm, just like I observed last week with external impingement.  You're essentially just going to go out of your way to avoid this "apprehension" position in the weight room by omitting exercises like back squats.  An apprehension test - illustrated in the most enthusiastic video in internet history - is a quick and easy assessment many doctors and rehabilitation specialists use to check for symptomatic internal impingement, as it reproduces the injury mechanism.

Second, and perhaps more importantly, you are dealing with two rotator cuff tears that are fundamentally different. It’s these differences that make me think doctors need to get rid of the term “impingement.” Here’s the scoop:

Let’s say that we have two guys with partial thickness tears of the supraspinatus – one from external impingement and one from internal impingement.

With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion). These issues will generally heal more quickly because the bursa actually has a decent blood supply.

With internal impingement, on the other hand, we’ve got an articular-sided tear, meaning that the wear on the tendon comes from underneath (glenoid). The tear is more interstitial in nature. Blood supply isn’t quite as good in this area, so healing is slower (or non-existent).

Traditionally, articular has been an athletic injury, and bursal has been a general population issue. This is not always the case, though.

Factor in the activity demands of overhead throwers, and they have more challenging tears and greater functional demands. Fortunately, they also typically have age and tissue quality on their sides, so things tend to even out.

With all these factors in mind, if a doctor ever tells you that you have "shoulder impingement," ask:

1. Internal or external?

2. If external, is it primary or secondary? (It’ll probably be both)

3. If internal, is there labral involvement? Biceps tendon?

4. If internal, what is the internal rotation deficit? (They should measure it, as this will begin to dictate the rehabilitation plan)

5. Given my age, activity level, and the nature of the tear, do you feel that surgical or conservative treatment is best?

Click here to purchase the most comprehensive shoulder resource available today: Sturdy Shoulder Solutions.

Sign-up Today for our FREE Baseball Newsletter and Receive Instant Access to a 47-minute Presentation from Eric Cressey on Individualizing the Management of Overhead Athletes!

In a blog last week, I discussed how important it is to differentiate between unstable surfaces and destabilizing torques applied further up the kinetic chain, as they comprise different kinds of instability training.

I receive a great question in response to the blog:

“Eric, what do you think about unstable surface training for hockey? I’ve been using half-dome stability balls for a long time now in many settings (high school through college) with my trainers. I can’t tell if the effect wouldn’t be the same if I were doing something else but skates do wobble under weak players when pivoting and stopping quickly under loads up to 2-3 times body weight, and ankles do adjust to become more stable after training like this. What’s your experience? Thanks, Boris”

It’s an interesting case, as the blade of a hockey skate is certainly different than regular flat surface.

Even more interestingly, though, is that Boris – through his question and also his personal experience – has directly highlighted some important research that was done in this regard.

In 2005, Behm et al. (1) examined the correlation between hockey skating speed and performance on a 30-second wobble board test. Interestingly, they found a significant correlation in players under the age of 19. However, no such correlation existed with players age 19 and older. So, how does this occur?

Here’s an analogy: go to a little league park, and find the kids who have the best fastball velocity. Chances are that they are also the kids who run the fastest, jump the highest, do the most chin-ups – or any other physical test that you throw at them. Very simply, this difference can easily be attributed to different levels of motor development in young skaters.  Heck, with just a quick Google search for "youth hockey," I came across this picture.

You'll notice that the physical development is markedly different across the board.  In fact, the 6-4, 230-pound goalie drove all the other 11-year-olds to the game, taught them how to shave, and then hit on all the hockey moms after the game at the local bar.

Moving back to the aforementioned Behm et al. study, the researchers noted, “The complex skills associated with skating would necessitate a more refined balance that would improve with maturity and perhaps training. Since skating is performed on a very small surface area (blade) in contact with a low friction surface, younger individuals with greater stability may have an advantage in executing the specific skating skills” (1).

So, in reality, we’re comparing physical development and not necessarily performance on a specific test – until we level the playing field and physical maturity is roughly equal for everyone (after the age of 18). At that point, you don’t see a correlation, so I’d be very reluctant to endorse lower-body unstable surface training as a useful training implement for hockey outside of specific rehabilitation situations.

The long-term studies examining the issue have been poorly controlled in the sense that they've looked at ankle sprains over the course of an extended period of time with an unstable surface training intervention, but haven't taken into account previous history  of injury.  So, the athletes engaged in the unstable surface training group may simply have been rehabilitating previous ankle injuries with longstanding functional deficits rather than "fortifying" already healthy ankles to prevent injuries.  Interestingly, in one study of elite female soccer players, balance board training did not decrease the rate of traumatic lower extremity injuries.  The frequency of major injuries - including four of five anterior cruciate ligament tears - was actually higher in the intervention (unstable surface training) group than the control group (2).

For more information, check out my new e-book, The Truth About Unstable Surface Training.

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