Home Posts tagged "Elbow Pain"

Exercise of the Week: Supported Elbow CARs

The benefits of controlled articular rotations (CARs) are now well known in the strength and conditioning and rehabilitation realms, thanks to Functional Range Conditioning teachings. One way in which we've evolved this approach is by taking a closer look at the position at which we perform our elbow CARs. Historically, they've been performed with the arms at the sides, like this:

However, I think there's a lot more benefit to be gained by performing them with the upper arms supported at 90 degrees of flexion, particularly in an overhead athlete population.

Here's why:

1. With more shoulder flexion, we are able to lengthen the long head of the triceps over both joints it crosses (elbow and shoulder). In the seated position, the long head of the triceps is actually shortened as a shoulder extensor.

2. In throwing athletes, you'll commonly observe Bennett's lesions, areas of increased calcification along the posterior glenoid rim. For most athletes, they're incidental findings in asymptomatic shoulders, but in some cases, they can get too big and cause rotator cuff pathology (I relate it to a speed bump that the cuff has to go over). While the true cause of Bennett's lesions has been debated in the sports medicine world, many are of the belief that it results from traction stress from the long head of the triceps (LHOT) tendon. The tendon attaches on the supraglenoid tubercle (which is on the inferior aspect of the glenoid) and extends up to the labrum and joint capsule. LHOT also eccentrically prevents excessive elbow flexion during the cocking phase of throwing (think of it being heavily lengthened in a shorter catcher-like arm action).

So, whether you believe it's related to Bennett's lesions or not, there's a strong anatomical basis for us to say that the long head of the triceps is an extremely important - but heavily underappreciated - muscle for overhead athletes. I've seen a lot of throwers over the years who've benefited tremendously from manual therapy on the triceps - and this mobility drill is a useful proactive initiative that'll help the cause as well.

3. At positions of 90 degrees of shoulder flexion or more, we get greater serratus anterior recruitment to drive the rotational component of scapular upward rotation - but also a reduction in latissimus dorsi tone that can restrict it. This is particularly important in athletic populations that tend to carry a lot of extensor tone and live in scapular depression and/or downward rotation. It also gives these folks a break from competing against gravity, so it can actually reduce protective tension of the upper traps.

4. Building on this last point, serratus anterior also works to preserve the convex-concave relationship between the scapula and rib cage, which is particularly important to address in the aforementioned athletes who may have acquired flat (extended) thoracic spines over years of extension/rotation. These athletes crave reaching, rounding, and rotating.

You can add this to a warm-up, use it as a filler, or plug it into a cooldown. Take your time with each rep, and be sure to drive not only full elbow flexion/extension, but also pronation/supination of the forearm.

If you're looking to learn a bit more about long head of the triceps, I'd encourage you to check out my Sturdy Shoulder Solutions course, as I delve into it quite a bit as part of my upper extremity functional anatomy module.

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Understanding and Managing Ulnar Nerve Hypermobility

After an Instagram post of mine last week generated quite a few inquiries on how to manage ulnar nerve hypermobility, I thought I'd record a follow-up video to dig in a bit deeper on the topic.

If you're looking to learn a bit more about the structure and function of the elbow (particularly throwing elbows), my presentation, Everything Elbow, would also be worth checking out.

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CSP Elite Baseball Development Podcast: Understanding the Throwing Elbow with Dr. Chris Ahmad

We're excited to welcome Dr. Chris Ahmad, team doctor for the New York Yankees, to this week's podcast. Dr. Ahmad goes into great detail on the throwing elbow with respect to anatomy, diagnostic challenges, surgical complexities, non-operative strategies, and biological interventions. He also touches on important lessons for players, parents, and coaches who want to avoid youth baseball injuries.

A special thanks to this show's sponsor, Athletic Greens. Head to http://www.athleticgreens.com/cressey and you'll receive a free 10-pack of Athletic Greens travel packets with your first order.

Show Outline

  • What makes the anatomy and function of the elbow so complex, specifically in throwing athletes
  • What the biggest mistakes are both surgically and diagnostically with respect to the elbow
  • Why injuries of the elbow aren’t as binary as partial and full tears and how professionals can better evaluate and understand the health of elbows in throwing populations
  • How UCL calcification and injury at a young age impacts the health of baseball players as they grow and advance in their career
  • What makes a Tommy John surgery successful from a surgical perspective
  • How Tommy John surgery has evolved since it was first performed in 1974
  • What the clinical implications are for Dr. Ahmad to perform an ulnar nerve transposition during UCL reconstruction surgery
  • What variables surgeons must consider when deciding where to take a tendon graft from for UCL reconstruction
  • How Dr. Ahmad manipulates grafts to ensure an elbow is strong and sturdy for his patients post-surgery
  • What key things Ahmad discusses with his patients as they begin their road to recovery post-surgery
  • What key benchmarks Dr. Ahmad looks for patients to progress to through the Tommy John rehab process
  • Why there isn’t a true standard timeline for athletes to return to performing in games after UCL reconstruction
  • Why Dr. Ahmad is an advocate for biological interventions such as PRP injections and the use of stem cells to manage elbow injuries, and what benefits these methodologies offer beyond throwing injuries
  • Where the future of biological treatments is headed, and what the drawbacks and dangers of using these powerful methods can be
  • Where Dr. Ahmad sees the need for more research to be done in the prevention, reconstruction, rehabilitation, and recovery of arm injuries
  • Why Dr. Ahmad has worked to create a registry with Major League Baseball to collect data on injured professional ball players and how this resource will be used to find answers to questions in the field without setting up a formal study

You can follow Dr. Ahmad on Twitter at @DrChrisAhmad and on Instagram at @DrChrisAhmad. And, you can learn more about him at www.DrAhmadSportsMedicine.com. Definitely check out his books:

Baseball Sports Medicine

Skill

Understanding Tommy John Surgery

Sponsor Reminder

This episode is brought to you by Athletic Greens. It’s an all-in-one superfood supplement with 75 whole-food sourced ingredients designed to support your body’s nutrition needs across 5 critical areas of health: 1) energy, 2) immunity, 3) gut health, 4) hormonal support, and 5) healthy aging. Head to www.AthleticGreens.com/cressey and claim my special offer today - 20 FREE travel packs (valued at $79) - with your first purchase. I use this product daily myself and highly recommend it to our athletes as well. I'd encourage you to give it a shot, too - especially with this great offer.

Podcast Feedback

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Thank you for your continued support!

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Strength and Conditioning Stuff You Should Read: 8/6/19

Today, I've got a list of recommended reading to get you through the week. Before we get to it, though, just a quick heads-up that we're doing a pre-sale on Cressey Sports Performance bucket hats. If you're interested in buying one, you can do so at THIS LINK. They'll be available for shipment in early-mid September.

As for the reading recommendations, check out the following:

Is It Really "Biceps Tendonitis?" - In light of a recent Instagram post I made on a related topic, this video blog deserves a reincarnation this week.

10 Habits that are Just as Important as Tracking KPI - My business partner, Pete Dupuis, wrote this article that examines some of the overlooked areas in which you can evaluate fitness business success.

Professional and Amateur Pitchers' Perspective on the Ulnar Collateral Ligament Injury Risk - This was an interesting study on a number of fronts. It was surprising to see how many pro guys think UCL injuries are unavoidable, but not at all surprising to hear that 55% of those who have UCL injuries in pro ball had a previous history of elbow injury in their youth baseball days. The biggest risk factor for an injury is...shocker...a previous injury.

Top Tweet of the Week

Top Instagram Post of the Week 

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The Best of 2018: Baseball Articles

With baseball athletes being the largest segment of the Cressey Sports Performance athletic clientele, it seems only fitting to devote a "Best of 2018" feature to the top baseball posts from last year. Check them out:

1. When Pitching Goes Poorly: 5 Strategies for Righting the Ship - Pitchers can struggle for many reasons beyond just mechanics. Here are five factors to take into account.

2. Is It Really Biceps "Tendonitis? - One of my biggest pet peeves is when all anterior shoulder pain is given a "blanket diagnosis" of biceps tendonitis. With that in mind, this webinar excerpt from my Sturdy Shoulder Solutions resource delves into the topic in greater detail.

3. How to Apply the Joint-by-Joint Approach to the Elbow - In this video blog, I discuss how we can apply the concept of regional interdependence to the elbow, particularly in the context of pitching injuries.

4. How to Win 99% of High School Baseball Games - I've haven't coached a high school baseball game in my life. I know a lot about adaptation to training in youth athletes, though, and that puts me in a unique position to comment on how to win high school baseball games.

5. Why Injuries are Highest Early in the Baseball Season (Video) - Major League Baseball Injuries are highest during Spring Training and early in the regular season. Surely, some of this has to do with the fact that some players had lingering issues from the previous season that never went away - but it definitely goes further than this.

We've got one last "Best of 2018" list running tomorrow, so stay tuned for the closer!

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How to Apply the Joint-by-Joint Approach to the Elbow

Today, I've got a video post for you, and it builds on the Joint-by-Joint approach that's been popularized by Gray Book and Mike Boyle. In the video, I discuss how we can apply the joint-by-joint theory to the elbow, particularly in the context of pitching injuries. Check it out:

If you're looking to learn more about the elbow, I'd encourage you to check out my presentation on the topic, Everything Elbow.

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Strength and Conditioning Stuff You Should Read: 6/15/18

It's been a quiet week here on the blog because I'm still recovering from last week's Sturdy Shoulder Solutions product launch and the barrage of college athletes who are all starting up at CSP at the same time. Luckily, I do have some good content from around the 'net for you:

Pat Rigsby on Building Your Ideal Fitness Business - Pat Rigsby is the man. I got this email from Mike Robertson in my inbox this morning and cleared time in my schedule to listen to this podcast right away. He always has great business insights for fitness professionals.

10 Strength and Conditioning Lessons from Friends, Mentors, and Colleagues - This is a great compilation from my buddy Todd Hamer, who's been a mainstay in the college strength and conditioning field for as long as I can remember.

Lessons Learned from a Bum Elbow - I posted this story on my Facebook page the other day, and there are a lot of lessons in here for fitness professionals and rehabilitation specialists, especially those who deal with throwing athletes.

Top Tweet of the Week

Top Instagram Post of the Week

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Random Thoughts on Sports Performance Training – Installment 19

It's time for the June installment of "Random Thoughts on Sports Performance Training."  With the introductory sale on Functional Stability Training: Optimizing Movement ending on Sunday at midnight, I'm going to use this post as an opportunity to highlight one of the key concepts that resounds throughout the product: relative stiffness.

FST-DVD-COVER-OPTIMOVE

1. All successful coaching hinges on relative stiffness - whether you're aware of it or not.

I first came across the concept of relative stiffness in reading Shirley Sahrmann's work. This principle holds that the stiffness in one region (muscles/tendons, ligaments, or joint) has can have a functional impact on the compensatory motion at an adjacent joint that may have more or less stiffness. You'll also hear it referred to as "regional interdependence" and the "joint-by-joint" approach by the FMS/SFMA and Mike Boyle, respectively.

For those who do best with examples, think of lower back pain in someone who has an immobile thoracic spine and hips. They don't move through these regions (excessive stiffness), so the lumbar spine (insufficient stiffness) just compensate with excessive motion. Likewise, a female soccer player with insufficient "good stiffness" in the hip external rotators and hamstrings might be more likely to suffer an ACL injury, as this deficit allows excessive motion into knee valgus and hyperextension.

This is why a knowledge of functional anatomy is so key for strength and conditioning coaches. Every cue you use is an attempt to either increase or decrease stiffness. When you hear Dr. Stuart McGill say, "lock the ribs to the pelvis," he's encouraging more (anterior) core stiffness. When you hear "double chin," it's to increase stiffness of the deep neck flexors. When you ask an athlete to take the arms overhead during a mobility drill, you're looking to decrease stiffness through the lats, thoracic spine, pec minor, etc. - and increase stiffness through the scapular upward rotators, anterior core, deep neck flexors, etc. 

laterallunge

In short, absolutely everything we do in training and in life is impacted by this relative stiffness.

2. Remember that elbow hyperextension doesn't only occur because of joint hypermobility.

I've written frequently about how elbow hyperextension at the top of push-ups is a big problem, especially in hypermobile athletes who may be more predisposed to the issue. Typically, this is simply a technique issue; you tell athletes to stop doing it, and they do.

elbowhyperextension

However, this doesn't mean that they'll automatically correct the tendency on other movements - like catching a snatch overhead, or throwing a baseball. It's when we look at the problem through a larger lens that we realize there is a big relationship to a lack of scapular motion. If you don't have enough good stiffness in serratus anterior to get the scapula to "wrap" around the rib cage and upwardly rotate, you'll have to go elsewhere to find this motion (elbow hypermobility). This is why I'm a huge stickler for getting good scapular movement on the rib cage - and the yoga push-up is a great way to train it. Think "more scap, less elbow."

3. If you want job security, become a hip surgeon.

The other day, I was speaking with a good friend who works with a lot of strength competitors - powerlifting, Olympic lifting, and Crossfit - and he made a comment that really stood out to me: "I'm seeing uglier hips than ever - even with females."

This has some pretty crazy clinical implications. Most females of "strength sport competitor age" have quite a bit of natural joint hypermobility, so they typically present with excellent hip range-of-motion prior to the age of 40. Even females who sit at computers all day rarely present with brutal hip ROM before they're middle-aged. What does this tell us? We have a lot of females who are developing reactive changes (bony overgrowth = bad stiffness) in their hips well too early, and when they later add increased ligamentous stiffness and a greater tendency toward degenerative changes (both normal with aging), we are going to see some really bad clinical hip presentations.

As an aside, it’s widely debated whether those with femoracetabular impingement (FAI) are born with it, or whether it becomes part of “normal” development in some individuals. World-renowned hip specialist Marc Phillipon put that debate to rest with a 2013 study that examined how the incidence of FAI changed across various stages of youth hockey. At the PeeWee (10-12 years old) level, 37% had FAI and 48% had labral tears. These numbers went to 63% and 63% at the Bantam level (ages 13-15), and 93% and 93% at the Midget (ages 16-19) levels, respectively. The longer one played hockey, the messier the hip – and the greater the likelihood that the FAI would “chew up” the labrum.

fai

Source: Lavigne et al.: http://www.ncbi.nlm.nih.gov/pubmed/15043094

So, whether it's strength sport athletes, hockey players, or some other kind of athlete, if you want job security, become a hip surgeon - and expect to do a lot of hip replacements in 2040 and beyond. There's a good chance these folks will need multiple replacements over the course of their life, too, if the longevity of the hardware doesn't improve before then. The same can probably be said for shoulders, too.

How does it relate to relative stiffness? Once you've used up all the "bad" stiffness you can acquire - muscles, tendons, ligaments, and joint - there's a good chance that you'll have beaten at least some structure up enough to warrant a surgery.

Wrap-up

I could go on and on with other examples of relative stiffness in action, but the truth is that they are countless - and that's why it's so important to appreciate this concept. To that end, I'd highly recommend you check out Mike Reinold and my new resource, Functional Stability Training: Optimizing Movement. It's on sale at an introductory $30 off discount through this Sunday at midnight.

eric and mike squat

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Preventing Baseball Injuries: Actions Speak Louder Than Words

We're at a point in time where just about everyone knows that throwing a baseball year-round is a bad idea. Moreover, we know that it's best for kids to avoid early sports specialization. 

Dr. James Andrews has been outspoken against early specialization and year-round throwing for roughly a decade.

John Smoltz devoted a big chunk of his Hall-of-Fame acceptance speech in Cooperstown to discouraging kids and parents from early specialization and year-round baseball.

JohnSmoltz

Seahawks coach Pete Carroll recently referred to the trend of kids playing only one sport as "an absolute crime."

USA Baseball launched their Pitch Smart campaign - featuring an advisory board of many MLB team doctors and athletic trainers - to prevent overuse in youth baseball.

All the way back in 2006, a landmark study by Olsen et al. clearly demonstrated strong associations between injuries requiring surgery and pitching "more months per year, games per year, innings per game, pitches per game, pitches per year, and warm-up pitches before a game" as well as showcase appearances during adolescence. Overuse is the one factor that predicts injury over and over again in the research.

A 2011 study demonstrated that players in warm weather climates had less shoulder strength and more problematic range-of-motion adaptations than those in cold weather climates. And, speaking from personal experience from having Cressey Sports Performance facilities in both states, it's been far more challenging to develop players in Florida than it is in Massachusetts. There is simply too much baseball competing with general athletic development.

These are just a few examples, too. Hundreds of professional athletes have spoken out against early sports specialization. College coaches have in some cases refused to recruit one-sport athletes. And, there are more anti-specialization posts and websites freely available on the Internet than one could possibly imagine. Yet, the problem isn't even close to going away, and injuries still at all-time highs.

Now, I can understand how some players, parents, coaches, and scouts don't stay on top of the American Journal of Sports Medicine and might have missed this important information. What I can't understand is how they'd miss it when the world's most recognized orthopedic surgeon is speaking out against it. Or how they can miss it when one of the most accomplished pitchers of the last century devotes the biggest media spotlight of his life to bashing early sports specialization. Or how they'd overlook one of the premier coaches in the NFL so vehemently putting down the practice. Or how a governing body like MLB would devote time, money, and resources to a problem that they think will have a significant negative impact on the future of the game beyond just the billions of dollars that are already being wasted on players on the disabled list.

The problem is not a lack of knowledge; the problem is a lack of action and consequences.

When you were a little kid and stole a cookie from the cookie jar - even after your mother told you it was off limits - you got punished for doing so. If you didn't have consequences, you'd keep stealing cookies. Unfortunately, this isn't an option with youth baseball. Really, the only consequence is injury, and it's surprisingly not that great a teacher.

elbows

A lot of kids and parents continue to make the same mistakes even after an arm surgery and extended layoff. They've been brainwashed to think that the only way kids can succeed in baseball is to play year-round to keep up with other kids and get exposure to college coaches and pro scouts. There are too many coaches, showcase companies, and scouting services lining their pockets by lobbying hard to make these false assumptions stick. 

If knowledge ("eating too many cookies is bad for you") isn't working, and it's hard to deliver consequences, what's the next step? You've got to make it really hard to get to those cookies - and they better taste like crap if you do manage to do so. 

Stepping away from this analogy, the big governing bodies that matter need to step up their game. Here are six quick changes that I personally feel could have a profound impact on reducing injury rates across all levels:

1. Major League Baseball needs to implement a high school scouting "dead period" from October 1 through January 1. It is entirely hypocritical for MLB to push PitchSmart, but turn a blind eye when literally hundreds of scouts are showing up for October-December showcases and tournaments that directly compete with the PitchSmart initiative. Most of the highest-profile players aren't even attending these events anymore (advisors know it's an unnecessary injury risk), and there is absolutely nothing a scout would see in November that they can't see in the spring during the regular season.

2. MLB should also mandate that no pitcher can throw in more than three consecutive games - including "getting hot" (throwing in the bullpen, but not entering the game). Some might criticize me for this, but after extensive interaction with relievers at this level, I firmly believe that bullpen mismanagement is one of the biggest problems in MLB pitching injuries. Fans and the media only see the actual number of appearances, but when you factor in the number of times a pitcher "gets hot" without entering the game, you have relievers who are literally throwing over 120 times in a season.

3. The NCAA needs to implement innings limits on freshman and sophomore pitchers. Keep freshman pitchers to 120 innings and sophomore pitchers to 140 (combining the college season and summer ball). Additionally, any pitcher who throws more than 120 innings during the spring/summer should have a mandatory 60-day period of no throwing prior to starting fall ball.

4. The NCAA should also implement a conservative pitch count limit for college starters. I think 130 is a good place to start, and while I still think it's unnecessarily high, it reins in those coaches who'll leave a guy in for 150+ pitches. Sadly, this happens far too often in college baseball these days, and there are zero repercussions (although I do commend ESPN's Keith Law for always calling these coaches out on Twitter).

5. State athletic associations in warm weather climates need to structure high school seasons to allow for athletes to compete in multiple sports. As an example, in Massachusetts, the high school baseball season begins on the third Monday in March, while the first basketball practice is November 30. If a high school basketball player wants to play baseball, he might only have a 1-2 week overlap during that month - and it only happens if his team goes deep into the playoffs.

Conversely, the high school baseball season here in Florida begins on January 18, while the last regular season basketball game doesn't occur until January 30. The state championship games take place February 23-27 - which is roughly halfway through the baseball season! There is absolutely no reason for a high school baseball season (in which teams play about 30 games) needs to start prior to March 1.

CSP-florida-021

That extra six weeks would make a huge difference in getting more baseball players to also participate in winter sports and help to get a baseball out of young hands a bit longer. And, you'd see a lot more players well prepared on day 1 of baseball tryouts because they'd have more off-season preparation under their belts. It would simply force teams to play three games per week instead of two; this is exactly what's done in Northern states (and they'll sometimes play four, if weather interferes).

6. Similar to point #4, state athletic associations should also have regulations on permissible pitch counts for high school arms. I think 115 pitches is a good number.

Closing Thoughts

I should note that I actually think Little League Baseball does a solid job of disseminating information and including specific regulations within the game and between games. The changes - at least in my eyes - should rest with high school athletic associations, the NCAA, and Major League Baseball. Impact will come from the top down.

As you can see, with only two exceptions, I'm much more about managing the competitive year than I am about micromanaging pitch counts. And, the two pitch count recommendations I put out are remarkably conservative and just reaffirm common sense (which, unfortunately, isn't so common anymore). Pitch counts alone haven't proven to be tremendously effective, but do have a place when implemented alongside guidelines for managing the overall baseball calendar.

There is absolutely no reason for skeletally immature middle and high school baseball players to have longer competitive seasons than professional players.

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The Best of 2014: Strength and Conditioning Videos

With my last post, I kicked off the "Best of 2014" series with my top articles of the year. Today, we'll highlight the top five videos of the year. These videos only include instructional videos, not quick exercise demonstrations.

1. Thoracic Mobility and Back Squatting - Upper back positioning is a key factor in squat technique, but not everyone starts in the same position. Check out the video to learn more:

2. Serratus Wall Slide Variations - Serratus anterior is an incredibly important muscle for shoulder health and function. Here are two exercises we use in our serratus anterior activation progression.

3. Do You Really Have Poor Ankle Mobility? - It's been my experience that ankle flexibility restrictions are really "overdiagnosed," and in reality, people just don't know how to shut off their plantarflexors (calves) as part of a heavily extended posture. I elaborate in this video:

4. Are You Packing the Shoulder Correctly? - It's important to be able to pack the shoulder, but in many cases, folks don't know exactly what is or should be going on functionally. This webinar should clarify.

5. Limited Shoulder Flexion in Pitchers - We often hear that shoulder dysfunction relates to elbow pain in throwers, but very rarely do we hear the "why" behind this link. In this video, I elaborate:

I'll be back soon with the top guest posts of 2014!

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