7 Random Thoughts on Corrective Exercise and Post-Rehab Training
Written on October 8, 2014 at 7:10 am, by Eric Cressey
If you've read much of my stuff (most notably this article), you likely appreciate that I think it's really important for fitness professionals to understand corrective exercise and post-rehab training. Folks are demonstrating poorer movement quality than ever before, and injuries are getting more and more prevalent and specific. For the fitness professional, corrective exercise can quickly become a tremendous opportunity - or a huge weakness. To that end, given that Dean Somerset put his great resource, Post-Rehab Essentials, on sale for $50 off through the end of the day, I wanted to devote some thoughts to the subject with these seven points of "Eric Cressey Randomness."
1. Refer out. - With more and more certifications and seminars devoted to corrective work, the industry has a lot more "corrective cowboys:" people who are excited to be able to "fix" everything. Unfortunately, while this passion is admirable, it can lead to folks taking on too much and refusing to refer out. To that end, I think it's important for us to constantly remind fitness professionals to not work outside their scope of practice.
Referring out is AWESOME. I do it every single day - and to a wide variety of professionals. It provides me with more information, and more importantly, helps me toward the ultimate goal of getting the client/athlete better. Trainers often worry that if they refer out, they'll lose money. This generally isn't true, but even if it was, it's a short-term thing. If you appreciate the lifetime value of the client, you'll realize that getting him/her healthy will make you more profitable over the long-term.
Additionally, I've developed an awesome network of orthopedic specialists in the greater Boston area. As a result, I can generally get a client in to see a specialized doctor for any joint in about 24-48 hours. It's an awesome opportunity to "overdeliver" to a client - but it never would have come about if I hadn't been willing to refer out. As an added bonus, we'll often get referrals from these doctors as well.
2. Ancillary treatments are key. - For my entire career, I've been motivated by the fact that I absolutely hate not knowing something. It's pushed me to always continue my education and not get comfortable with what I know, and it's helped me to be open-minded to new ideas. However, I'm humble enough to recognize my limitations. I know a lot about elbows, but I'm not going to do your Tommy John surgery. I've worked with more pitchers than I can count, but I'm not a pitching coach. And, even if I was able to do all these things, there's no way I'd have time to do them all and leverage my true strengths. In other words, I rely heavily on competent professionals around me for everything from sport-specific training, to manual therapy, to diagnostic imaging, to surgery, to physical therapy, to nutritional recommendations. Surround yourself with great people with great skillsets, and corrective exercise quickly becomes a lot easier.
3. Soft tissue work is effective.
Here's what I know: people feel better after they foam roll, and their range of motion improves. Additionally, soft tissue treatments have been around for thousands of years for one reason: they work!
For some reason, though, every 4-6 months, somebody with a blog claims that foam rolling is the devil and doesn't work, and then dozens of people blow up my email address with questions about whether the world is going to end.
The truth is that we know very little about why various soft tissue approaches work. I recall a seminar with bodywork expert and fascial researcher Thomas Myers from a few year back, and he commented that we "know about 25% of what we need to know about the fascial system." If Myers doesn't have all the answers, then Johnny Raincloud, CPT probably hasn't found the secrets during his long-term stay in his parents' basement.
With that in mind, I do think it's safe to say that not all people respond the same to soft tissue work, and certainly not all soft tissue approaches are created equal. Foam rolling doesn't deliver the same results as an instrument-assisted approach, and dry needling likely works through dramatically different physiological avenues than cupping. As a result, we're left asking the client: "does it make you feel and move better?" If the answer continues to be "yes," then I'll keep recommending various soft tissue treatments - including foam rolling - until someone gives me a convincing contrarian argument with anecdotal evidence.
4. Strength can be corrective.
Ever had a friend with anterior knee pain (patellar tendinopathy) who went to physical therapy, did a bunch of leg extensions, and somehow managed to leave asymptomatic? It was brutally "non-functional" and short-sighted rehab, but it worked. Why?
Very simply, the affected (degenerative or inflamed) tissues had an opportunity to rest, and they came back stronger than previously. A stronger tissue is less likely to become degenerative or inflamed as it takes on life's demands.
Good rehab would have obviously focused on redistributing stress throughout the body so that this one tissue wouldn't get overloaded moving forward. In the patellar tendon example, developing better ankle and hip mobility would be key, and strength and motor control at the hip and lumbar spine would be huge as well. Certainly, cleaning up tissue quality would be a great addition, too. However, that doesn't diminish the fact that a stronger tissue is a healthier tissue.
This also extends to the concept of relative stiffness. As an example, a stronger lower trapezius can help to overcome the stiffness in the latissimus dorsi during various upper extremity tasks.
And, a stronger anterior core can ensure corrective spine and rib positioning during overhead reaching - again, to overcome stiff lats.
Don't ever forget that it's your job to make people stronger. If you get too "corrective" in your mindset, pretty soon, you've got clients who just come in and foam roll and stretch for 60 minutes, then leave without actually sweating. You still have to deliver a training effect!
5. Minimalist sneakers might be your worst nightmare if you have high arches.
I love minimalist sneakers for my sprint and change-of-direction work. I don't, however, love to wear them on hard floors for 8-10 hours a day. I'm part of the small percentage of the population that has super high arches and doesn't decelerate very well, so cushioning is my best friend. Throwing in a $2 "cut-to-fit" padding in my sneakers has done wonders for my knees over the years, and I'll actually wear through them every 4-6 weeks.
The New Balance Minimus 00 is a sneaker I've been wearing recently to overcome this. It's a zero drop shoe (no slope down from the heel to the toe), and while lightweight, it offers a bit more cushioning (and lateral support, for change of direction) than typical minimal options.
All that said, just don't force a round peg in a square hole with respect to footwear. Some people just aren't ready for minimalist footwear - and even if they are ready to try them out, make sure you integrate usage gradually.
6. The pendulum needs to swing back to center with respect to thoracic spine mobilizations. - Thoracic spine mobility deficits are a big problem in the general population, given the number of people who spend too much time sitting at a computer. Athletes are a bit of a different situation, though, as some actually have flat (excessively extended) thoracic spines and don't need more mobility. As an example, check out the top of this yoga push-up before we corrected it.
This athlete has a flat thoracic spine, limited shoulder flexion, and insufficient scapular upward rotation. So, he'll logically go to the path of least resistance: excessive thoracic motion (as evidenced by the "arch" in his upper back). The shoulder blades don't rotate up sufficiently, and he's also "riding" on the superior aspect of his glenohumeral (shoulder ball-and-socket) joint. Here is it, "mostly" corrected a few seconds later:
By getting him to "fill up" the space between his shoulder blades with his rib cage (encouraging more thoracic flexion) and cueing better upward rotation of his scapula, we can quickly recognize how limited his shoulder flexion is. In the first photo, he's forcing shoulder ROM that isn't there, whereas in the second one, he's working within the context of his current mobility limitations.
If we just feed into his thoracic spine hypermobility with more mobilizations, we'll just be teaching him to move even worse.
7. You'll never address movement impairments optimally unless nutrition and supplementation are spot on. - It never ceases to amaze me how many athletes will bust their butts in the gym and in rehab, following those programs to a "T" - but supplement that work with a steady diet of energy drinks and crappy food. I'm not talking about debating whether grains and dairy are bad, and whether "paleo" is too extreme for an athlete; those are calculus questions when we should be talking about basic math. A lot of athletes literally don't eat vegetables or drink enough water. That's as basic as it comes. Movement quality will never improve optimally unless you're healthy on the inside, too.
This article was actually a lot of fun to write, so I'll probably turn it into a series for a bit down the road. In the meantime, though, I'd encourage you to check out Dean Somerset's Post-Rehab Essentials resource to learn more in this regard. I don't hesitate to endorse this comprehensive corrective exercise resource, as the content is fantastic, Dean is an excellent teacher, and the product provides some continuing education credits. The $50 off just sweetens the deal. Check it out HERE.
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October 8th, 2014 at 7:49 am
Couldn’t agree more with number 7 Eric :).
October 8th, 2014 at 7:58 am
Awesome article, man!
A small sidenote:
In the text for the “Post rehab” series that is on sale this week, the writer explains that “static stretching is absolutely useless, and should be avoided if….”
The up-to-date litterature shows that static stretching is the most optimal resource if you want to increase ROM in a joint, and that dynamic and isometric stretching (which is static to a certain extent) work less efficiently. Most of my clients have heeeeeeeeeelluva tight adductors and gluteals. How is it justified that increasing their ROM through controlled static stretching is counter-productive (combined with ROM exercises like squats etc ofc)?
I mean, of course I understand that static stretching should absolutely be avoided in hypermobile clients and in certain injury or pathological circumstances, but to call static stretching “absolutely useless”.
I don’t get the rationale.
What’s your viewpoint on this?
(sorry for the length of the post)
Also: Loving the point on soft tissue work. I do a lot of soft tissue work in my practice, and it’s always worked wonders for both pain and function.
October 8th, 2014 at 10:49 am
Eric-
With IASTM, petechia is my clue to stop. Do you feel there is a point when “rolling” on tissue turns into mashing tissue? What is that point…?
Mark
October 8th, 2014 at 2:16 pm
“Those are calculus questions when we should be talking about basic math”
“Movement quality will never improve optimally unless you’re healthy on the inside, too.”
Two of the truer points I’ve read all month. In addition to nutrition and exercise as you’re discussing I also stress the balance of 3 parts of that basic math equation:
Nutrition + Exercise + Recovery = Fitness and Performance
If any one of these are neglected, the other two aren’t as effective. If you work your tail off in the gym and even eat like an animal but fail to get sufficient good-quality sleep, you’re missing out on very specific cycles where protein synthesis takes place. If you train to win, sleep like a sloth, but eat like a slob its like trying to build a sky scraper out of twizzlers and expect it not to wilt.
Great points and more people should be having this discussion with their athletes/clients.
SG
October 8th, 2014 at 2:17 pm
PS, yes, corrective exercise is also included in the recovery portion of that equation.
October 8th, 2014 at 3:42 pm
Mark,
Really tough to say. My experience has been that some athletes do better with more aggressive treatments, and others need it lighter. And, skin response is a very individual thing.
October 9th, 2014 at 3:23 am
As a strength and conditioning coach and final-year Doctor of Physiotherapy student, this is a great article to read! Personal training/coaching gets a bad rap because of the “Johnny Raincloud, CPT’s” of the world who are undereducated, overly confident and whose modus operandi is defined by an unlimited scope of practice. This article is one of hundreds that sets EC apart from 99% of the field…
October 9th, 2014 at 5:51 am
Eric,
Do you recommend the “Post Rehab Essentials” to athletes as well? Or just trainers?
Thanks,
Jim
October 9th, 2014 at 3:28 pm
Scott, briefly about nutrition we know good nutrition is important but even with good nutrition poor movement will not allow absorption of nutrients to get the benefit from good eating
October 9th, 2014 at 8:22 pm
Jim,
I think athletes can learn a lot, too.
April 24th, 2016 at 10:57 am
I have high arches and I wrecked my ankle and tore a ham in minimalists. They make me supinate even more than I do now. They have proven to be very unstable during outdoor activities and I regret not getting more stable and cushioned for the outdoors.
April 24th, 2016 at 11:07 am
Great read, thanks for sharing this Eric!
I’m in the need of more overhead shoulder flexion as well, and it’s something that’s really limited me. #6 was a great example, and something I’m going to try next time I hit some yoga push-ups.