It's been a quiet week on the blog, as my wife and I traveled up to Massachusetts for a long-time client's wedding and the last Elite Baseball Mentorship of the year.
I'll have some new content for you later in the week, but in the meantime, here's some great stuff to cover:
30 Days of Arm Care - I wrapped this up a few days ago. You can view all the videos on Twitter and Instagram using the #30DaysOfArmCare hashtag.
The Fitness Entrepreneur's Handbook - Pat Rigsby is one of the brightest business minds I've ever met - and certainly among the top guys in the business of fitness. I was thrilled when he asked me to write the foreword to this new book. This is a must read if you're in the fitness industry.
5 Lessons on Coaching - I published this guest blog from former Cressey Sports Performance intern John O'Neil one year ago, and it was a huge hit. There are definitely some great coaching lessons in here.
Top Tweet of the Week
Maybe the problem isn't the weighted balls. Maybe it's one coach giving an entire team of 14-year-olds the exact same weighted ball program.
Today, we have a guest blog from former Cressey Performance intern Eric Oetter, who is well on his way to a great career in physical therapy. Eric is an extremely bright up-and-comer from whom you'll be hearing a lot in the years to come. Here's a little sampling.
As part of the “pre-launch” phase for his new collaborative project, Elite Training Mentorship, Eric posted an outstanding video covering the lower-extremity assessment protocol he uses at Cressey Performance. For those who haven’t yet seen it, follow the link here; you won’t regret it.
In the video, Eric mentions three different factors that can contribute to mobility deficits at the hip: muscular restrictions, capsular restrictions, and bony restrictions. While the first two – muscular and capsular – can be relatively easy to decipher based on the test position of the hip, identifying bony restrictions can be tricky unless you’ve got access to a client’s radiological imaging. For this reason, it’s important to appreciate any structural variations in the skeletal system that can underlie joint malalignment at the hip.
The focus of this piece is a structural variation called hip anteversion. We’ll be covering the joint morphology associated with anteversion, along with a quick orthopedic test and some implications for programming.
What is hip anteversion?
Excerpted from the 2002 text Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann describes hip anteversion as the following:
“ … the angle of the head and neck of the femur is rotated anteriorly, beyond that of the normal torsion with respect to the shaft. The result is a range of medial hip rotation that appears to be excessive, whereas the lateral rotation range appears to be limited.”
Essentially, clients who present with this structural abnormality were born with, or have acquired, a more internally oriented neutral position for their femurs as they sit in the acetabulum (or hip socket). To be classified as anteverted, the femoral head and neck must be rotated more than 15° anteriorly with respect to the plane of the femoral condyles (Sahrmann 2002). (Conversely, a posterior rotation of the femoral head and neck would constitute a retroverted hip.)
When observed standing, clients with hip anteversion will often present with femoral adduction and genu valgum – the classic “knock-kneed” posture. As kids, these clients likely eschewed “indian-style” for W-sitting – a position much more congruent with their natural femoral alignment.
While some might also classify “pigeon-toes” as an indicator for anteverted hips, this is not always the case. In the presence of anteversion, some clients – especially athletes – will develop a tibial torsion as a result of the applied stresses to the lower extremities. This adaptation allows for a neutrally aligned sub-talar joint in the face of morphological changes up the kinetic chain.
The largest implication of hip anteversion or retroversion is a significant discrepancy between hip internal and external rotation. As described in the Sahrmann quotation above, hip anteversion creates an apparently large amount of internal rotation (IR) with a reciprocal loss of external rotation (ER).
I liken these morphological changes to those seen in the retroverted shoulder of an overhead throwing athlete. The total hip range of motion (IR + ER) can present at around 90°, or “normal”, but these measures are drastically skewed in one direction of rotation.
Whereas a retroverted shoulder presents a favorable adaptation in baseball, the same cannot always be said for the athlete with anteverted hips.
If undiagnosed or mismanaged, hip anteversion can create pathology. Expect issues like knee pain, back pain, and hip instability (Sahrmann 2002). For this reason, it’s imperative to recognize anteversion when it presents and apply the programming modifications necessary to accommodate this structural abnormality.
So how can I test for it?
Although checking IR and ER in both supine and prone can highlight limitations in the capsule or surrounding hip musculature, you’ll need an extra orthopedic test at your disposal to clear the skeletal system. For this purpose, we’ll use the Craigs’s test.
Assuming you’re following the assessment outlined in Eric’s video, the best time to perform a Craig’s test is immediately after you’ve assessed a client’s hip rotation in prone, especially if you detect a glaring asymmetry between IR and ER.
Note the client in the photos below – here, we see an excessive amount of IR (~50°) met with limited ER (only ~20°). With a rotational deficit of ≥30°, this client may have some torsional issue at play; thus, a Craig’s test indicated.
With the client remaining in prone the knee held in flexion, the Craig’s test is performed by first palpating the same side greater trochanter, a landmark on the femur that protrudes laterally about 5 inches below the iliac crest. Make sure to apply flat-hand contact with the pads of the fingers – this posture allows for greater sensory feedback and precision. Once this position is assumed, begin internally and externally rotating the femur through its full range of motion.
As you rotate the leg, you’ll notice the greater trochanter tracking against your fingertips, becoming more or less prominent depending on the direction of rotation. Start shortening your oscillations until you determine the position at which the trochanter is most prominent laterally and pause once you locate it. At this range of rotation, the femoral head is optimally situated within the acetabulum.
We get a positive Craig’s test when the hip rotation at the point of ideal femoral alignment is ≥15° into IR. Also, we can now classify the hip as anteverted, providing useful insight for the dexterous coach.
Check out the video below to see a Craig’s test performed on our client from above.
One thing worth noting – a 1992 study by Ruwe et al. showed the Craig’s test to be more reliable than radiological techniques in the assessment of femoral torsion. So, even if you have client X-rays available, a Craig’s test is still worth administering.
If the Craig’s test is positive, how should I alter programming?
Now that we’ve performed a Craig’s test and determined whether or not any torsional qualities exist, it’s time to write an effective program that respects our findings. Here are a few do’s and don’ts to consider when programming:
• DON’T stretch the hip into external rotation – this only creates impingement. We wouldn’t force the retroverted shoulder of a pitcher into an end-range sleeper stretch, so we need to take the same approach with an anteverted hip. Even though the hip is a much more durable joint, there’s no reason to drive motion that a client simply doesn’t have, as this only serves to jam the femoral head against the acetabulum.
• DO increase the amount of core work in clients with femoral torsion. When someone is stuck in internal rotation at the hip, the kinematics of the lower-extremities become predisposed towards a pronation pattern (sub-talar pronation, tibial/femoral IR, and anterior pelvic tilt).
The hip external rotators often become excessively stiff and overused, as they are constantly checking motion into adduction, internal rotation, and flexion. While increasing external rotator strength will improve the first two, we can employ the posterior fibers of external oblique and rectus abdominis to aid in flexion control, creating a more stable pelvis. By doing so, we’re also increasing stiffness at the lumbar spine, fighting any compensatory motion created by the hip external rotation deficit.
As far as exercise selection goes, focus on half-kneeling chops/lifts and anti-extension – both integrate the hips and core simultaneously to check hip flexion ROM. I especially like rollout variations for clients with hip anteversion, which are highlighted in Eric’s video below.
• DON’T introduce quad-dominant lifts until the client shows dramatic improvements in hip stability. The pronation pattern I described above is essentially a cookbook for ACL and MCL injuries. In a population that is likely anteriorly tilted at the pelvis and anterior weight bearing, the last thing we want to do is make them even more reliant on their quads. An adroit posterior chain should precede any anterior chain-focused movement.
• DO hammer the posterior chain as if your life depended on it. While this statement could serve as a mantra for most general population programming, it is even more important when dealing with anteversion of the hip. These clients sometimes present with femoral control so poor, our first goal is to simply get them to baseline.
Mastering stability in the sagittal plane takes precedence. Start bilateral with deadlift and box squat variations and increase stability demands as the client advances. Great second tier progressions include single-leg RDLs, single-leg hip thrusts, and bowler squats, all of which introduce frontal and transverse plane stability.
Lastly, exercises that force the femur into an abducted and externally rotated state are contraindicated – sumo deadlifts provide a great example. Even though pulling sumo is a fantastic variation for hip strength, it can create malalignment in the acetabulum if the hip is anteverted. In this case, it’s safer to stick with either trap bar deadlift or conventional deadlift variations.
Conclusion
Hip anteversion isn’t something you’ll likely see in every client. Johns Hopkins Medical School reports the prevalence to be ~8-10%, but that number varies based upon cultural norms and neurodevelopmental patterns, which can alter skeletal growth.
Regardless, it is an important structural variation to recognize and program for, especially in an athletic population. Taken as supplement to Eric’s lower-extremity video, I hope this article provides you another piece towards building a better assessment.
About the Author
Eric is currently a senior at the University of Georgia majoring in Exercise and Sport Science, with plans to pursue a Doctorate of Physical Therapy. After concluding a Division-1 football career at the Georgia Institute of Technology, Eric has ardently pursued his passion for coaching, garnering experience with clients of all ages and ability levels through internships at both Indianapolis Fitness & Sports Training and Cressey Performance. His articles can be found on EricCressey.com, 8weeksout.com, and in Fighting Fit magazine. You can follow him on Twitter or reach him via email at ecoetter@gmail.com.
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Show and Go: High Performance Training to Look, Feel, and Move Better - This was obviously my biggest project of 2010. I actually began writing the strength and conditioning programs and filming the exercise demonstration videos in 2009, and put all the "guinea pigs" through the four-month program beginning in February. When they completed it as the start of the summer rolled around, I made some modifications based on their feedback and then got cracking on writing up all the tag along resources. Finally, in September, Show and Go was ready to roll. So, in effect, it took 10-11 months to take this product from start to finish - a lot of hard work, to say the least. My reward has been well worth it, though, as the feedback has been awesome. Thanks so much to everyone who has picked up a copy.
Optimal Shoulder Performance - This was a seminar that Mike Reinold and I filmed in November of 2009, and our goal was to create a resource that brought together concepts from both the shoulder rehabilitation and shoulder performance training fields to effectively bridge the gap for those looking to prevent and/or treat shoulder pain. In the process, I learned a lot from Mike, and I think that together, we brought rehabilitation specialists and fitness professionals closer to being on the same page.
Why President Obama Throws Like a Girl - A lot of people took this as a political commentary, but to be honest, it was really just me talking about the concept of retroversion as it applies to a throwing shoulder - with a little humor thrown in, of course!
Overbearing Dads and Kids Who Throw Cheddar - This one was remarkably easy to write because I've received a lot of emails from overbearing Dads asking about increasing throwing velocity in their kids.
What I Learned in 2009 - I wrote this article for T-Nation back at the beginning of the year, and always enjoy these yearly pieces. In fact, I'm working on my 2010 one for them now!
The Skinny on Strasburg's Injury - I hate to make blog content out of someone else's misfortune, but it was a good opportunity to make some points that I think are very valid to the discussion of not only Stephen Strasburg's elbow injury, but a lot of the pitching injuries we see in youth baseball.
Surely, there are many more to list, but I don't want this to run too long! Have a safe and happy new year, and keep an eye out for the first content of 2011, which is coming very soon!
Seriously? This is all the retroversion an Olympic gymnast has? See what happens when you specialize in one sports early? You get a gold medal, but get laughed at by all 27 people in attendance at a minor league baseball game.
PS - Think this cameraman was drunk, or just laughing so hard that he couldn't keep the camera steady?
Many baseball fans thought that it was a bit inappropriate of President Obama to wear a Chicago White Sox hat as he threw out the opening pitching at the Washington Nationals game several years ago. However, many others - including those of us on the baseball development side of things - overlooked this fashion faux pas, and instead pointed out that the commander-in-chief's throwing mechanics closely paralleled those of an 11-year-old girl.
Now that I've irritated a good chunk of my readership, please allow me to explain.
We are all born with a certain amount of humeral retroversion. For the lay population out there, think of retroversion as a bony positioning that allows for more shoulder external rotation. As we age, we actually gradually lose retroversion (gain anteversion); this process moves the most quickly from ages 8-13, which isn't surprising, as this is when kids rapidly become more skeletally mature. It's why we see more torn ACLs than broken bones in the late teenage years; the bones are no longer the path of least resistance.
However, we actually see something different in kids who are involved in overhead throwing sports during this crucial developmental period. They don't gain anteversion as quickly in their throwing shoulder; in other words, they preserve at lot of the bony positioning that gives rise to external rotation (the lay-back position), which in itself is a predictive factor for throwing velocity. Very simply, it's easier for them to get their arm back to throw because the bones (specifically, the proximal humeral epiphysis) have morphed to allow for it. There's even a theory out there that this bony positioning actually spares the anterior-inferior glenohumeral ligaments from excessive stress during external rotation, but that's a topic for another day (and president?).
How much of a difference are we talking? Well, in a study of 54 college pitchers, Reagan et al. found that had 36.6° of humeral retroversion, as compared with just 26° in non-dominant shoulders. Here's our fearless leader throwing a cream puff from a different angle at a previous All-Star Game; you'll notice that he leads with the elbow and his arm doesn't "lay back" - a technique we've come to term "throwing like a girl," as politically incorrect as it is. Think he could use an additional 10° of shoulder external rotation?
The good news, however, is that he's in good company; Mariah Carey has sold hundreds of millions of albums and rocks a 12-foot palmball, too.
We can't fault these folks (well, maybe for their attire, but that, too, is another blog post), as females traditionally haven't had exposure to baseball at young ages in order to develop these osseous (bony) adaptations that favor throwing hard. And, with just a little reconnaissance work on President Obama, I quickly came across this quote from him in the NY Daily News: "I did not play organized baseball when I was a kid, and so, you know, I think some of these natural moves aren't so natural to me." There's your answer.
Contrast his delivery with that of George W. Bush, who not only played baseball as a kid, but actually owned the Texas Rangers for a while, and you'll see what a few years in Little League will do for a shoulder.
Interestingly, the Iraqi journalist who threw his shoes at Bush actually displayed some decent lay-back, too. It makes me wonder if he was born with some congenital laxity, played cricket or tennis, or just practiced a ton for his first international shoe-throwing appearance (cap?).
As an interesting little aside, in our Optimal Shoulder Performance, Mike Reinold talks about how European soccer players have actually served as the control group against which we can compare overhead throwing shoulders in research, as these athletes are the same age and gender as baseball pitchers, but rarely participate in overhead throwing sports. So, perhaps we should say "throw like a European soccer player" instead of "throw like a girl" - particularly since more and more female athletes have started participating in overhead throwing sports at a younger age!
However, in the interim, what can President Obama do to get over this hurdle? It goes without saying that it's too late to get that retroversion, as he's already skeletally mature. However, there is research out there that shows that pitchers gain external rotation over the course of a competitive season - so President Obama would be wise to get out in the rose garden and play some catch because, you know, presidents have plenty of time to do that!
Likewise, there are several things he could do to improve his pitching-specific mobility. The most important thing is to avoid spending so much time hunched over a desk, as being stuck in this position will shorten the pectoralis major and minor, lats, subscapularis, and several other small muscles that need adequate length and tissue quality to get the arm "back" via good humeral external rotation, scapular posterior tilt, and thoracic spine extension/rotation. To keep it simple, I'd probably just have him do a lot of the side-lying extension-rotation drill:
Of course, there's a lot more to it than just this, but these quick modifications would be a good start. For more information, check out our new Optimal Shoulder Performanceresource, which is on sale for 20% off through the end of the day today. Just enter the coupon code 20OFF to get the discount.
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Happy St. Patrick's Day! I was actually going to take today off - not just in honor of my Irish heritage, but because I was hoping to work from home and catch up on work. As it turns out, I went in to the facility for our staff in-service (given by Brian St. Pierre, who is featured below), some coaching of a dozen or so of our in-season baseball guys, and a quick training session of my own. Long story short, my "day off" turned into six hours at the facility, plus almost three hours in the car thanks to Boston traffic and a bunch of detours due to flooding after all the rain we've received.
Long story short, all this means that I didn't get around to writing a blog today - but fortunately for me, a few other bright minds did:
The China Study Fallacy - This is a great piece from Brian St. Pierre on how flawed the perspectives of many "experts" is when it comes to interpreting the results of the China Study. It's an awesome read.
Measuring Humeral Retroversion - This blog from Mike Reinold will interest those in the crowd who are (like me) shoulder geeks. If you train overhead throwing athletes, you definitely better understand retroversion. It's a concept Mike and I spend considerable time on in our new Optimal Shoulder Performance DVD set.
The Proactive Patient - This is definitely one of the articles that I enjoyed writing the most, as it teaches people to be advocates for themselves during the process of trying to get/stay healthy.
Q: As far as the total motion concept goes, is there a certain minimum of total degrees of motion that the "baseline" limb should have? For example, if a right-hand dominant person has fairly limited total motion on the left side and even more limitations on the right, would the goal be to get total motion symmetrical first and then improve both from there?
A: It is definitely population-specific, as overhead throwing, for example, will simply move that total motion to a different range. So, a symmetrical shoulder might be:
Right (dominant): 45° IR + 125° ER = 170° Total Motion
Left (non-dominant): 55° IR + 115° ER = 170° Total Motion
The difference between the two would be attributed to retroversion (bony adaptations - more info HERE). A 10° internal rotation deficit would be completely normal in a unilateral overhead throwing population.
Of course, if you get a freestyle swimmer, thinks get a bit interesting. You have to go a bit more by end-feel, and mandate that they have at least 25° degrees of total internal rotation.
That said, in a "normal" weight training population, I like to have at least 90° of external rotation and 50+° of internal rotation. I wouldn't consider those "good" measurements, but they would be workable (assuming symmetrical total motion).
Now, you are going to have situations here and there where someone has lost total motion in the non-dominant side. My experience has been that this occurs in athletes who spend too much time in computers and those who get "100% shut down" after an injury.
Believe it or not, I once saw a pro pitcher with only 6° (yes, single digits) of internal rotation on his throwing shoulder, and the medical staff's conclusion was to give him a cortisone shot and make him rest completely - no lifting, sprinting, stretching, anything (I wonder if they assigned an intern to him to help him wash his hair in the shower). He basically just charted pitches for two months. This guy lost total motion bilaterally, so the fact that he was forced into inactivity actually made his subsequent evaluation a bit more complex. The good news is that these guys can generally be recognized by their terrible thoracic spine posture and increased body fat levels!
