In this installment of "Exercise of the Week," I want to introduce you to another great carrying variation you can use to accomplisha number of different objectives. The 1-arm Bottoms-up Kettlebell Waiter's Walk is one of my personal favorites, and we use it a lot with not only our baseball guys, but also many of our non-baseball clientele.
Those of you who have followed my "Exercise of the Week" series probably notice that this is a progression on a previous drill I introduced, the 1-arm Bottoms-up KB Carry. To bring you up to speed on the "why" behind this kettlebell exercise, here are a few reasons it's a great one:
1. It gets great reflexive rotator cuff activation in light of the bottoms-up position and the subtle perturbations to stability as the individual walks.
2. It teaches an athlete to fully upwardly rotate the scapula (shoulder blade) correctly, which helps us to build stability in an overhead position and solidify the mobility we have. This is wildly important for overhead throwing athletes, too, as they always lose upward rotation over the course of the competitive season.
3. It creates a challenge to both lateral/rotary and anterior core function. The individual has to work to prevent excessive lower back arching, as well as side bending. Being able to get these challenges while still working the shoulder girdle ensures that you get great functional carryover to the real world.
4. Without even knowing it, you're also getting a pretty good grip workout simply from holding the slightly thicker handle of the kettlebell.
In addition to the coaching cues I discuss in the video above, one "outcome" measure for which you'll want to look is the amount of scapular upward rotation present. You can do that by drawing a line along the medial (inside border) of the scapula, and then checking what angle it creates with a vertical line along the spine. Your goal is about 55-60 degrees of scapular upward rotation.
In a good overhead position, you shouldn't feel it at all in the top or front of your shoulder. If you do, though, it's a sign that you're probably either lacking scapular upward rotation or don't have sufficient cuff strength to do this correctly. I always tell athletes that they shouldn't "feel" this in one place; it should feel like the entire shoulder girdle is working synergistically to create good stabilization.
Also, a lot of people will ask if they need to "pack the shoulder down with the lat." Why you would want to turn your lat on to reach overhead is a puzzle to me, as it limits shoulder flexion and scapular upward rotation, draws the humerus into internal rotation (closes down the subacromial space), and pulls the spine into an extended position (excessive arching). What folks really should be doing is a subtly posterior tilting the scapula to free up space at the front of the shoulder, and facilitate upward rotation. It's a flawed movement if you're just cranking the entire shoulder girdle down. In short, we want lower traps, not lats.
If you're looking to learn more about how I incorporate many different carrying variations in my programming, I'd encourage you to check out my new resource, The High Performance Handbook.
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Here's this week's list of recommended strength and conditioning reading:
Elite Training Mentorship - The August update at Elite Training Mentorship included some great content from all four contributors. My in-services were "Shoulder Impingement: Internal vs. External" and "Preventing and Training Around Flexion-Intolerant Low Back Pain." I also had an article and two exercise demonstrations featured. If you haven't checked out ETM, definitely do so!
Do Eggs Cause Heart Disease? - In the past week, the "Eggs Are Worse than Cigarettes" shenanigans have gotten out of control. Fortunately, Adam Bornstein (with contributions from Dr. Chris Mohr, Alan Aragon, and Mike Roussell) gets to the bottom of some very flawed research and reporting that is misleading the public.
As you can probably imagine, given that I deal with a ton of baseball players - and the fact that I've written about shoulder pain a ton over the past decade - a lot of people initially come to Cressey Performance because their shoulder hurts. It might be rotator cuff pain, AC joint irritation, or any of a host of other issues, but you'd be surprised at how many similarities there are among the ways that you address most of these issues.
The problem is that pain can throw a wrench in your plans and limit you in your ability to get to exactly where someone needs to improve movement-wise. For instance, you might have someone who has a significant glenohumeral (ball-and-socket) internal rotation deficit, but it's hard to manually stretch them into internal rotation without further irritating a cranky AC joint. Or, someone with a partial thickness rotator cuff tear may be dramatically limited in shoulder flexion, but even shoulder flexion with assisted scapular posterior tilt and upward rotation exacerbates their symptoms. Very simply, you can't just pound round pegs into square holes when it comes to dealing with a delicate joint like the shoulder - and that applies to both asymptomatic and symptomatic shoulders.
To that end, there are three initiatives that I think are the absolute most important places to start in just about every case.
First, I'm a huge advocate of soft tissue work with a skilled manual therapist. In our office, we have a massage therapist and chiropractor who performs both Active Release and Graston. And, we make sure that any physical therapist to whom we refer clients uses manual therapy as an integral part of their treatment approach. Whether you're a regular exerciser or not, tissues can get dense, nasty, and fibrotic, and integrating some hands-on work on the pec minor, posterior rotator cuff, lats, scalenes, sternocleidomastoid, and several other areas can dramatically reduce an individual's symptoms and improve range-of-motion instantly - and that allows us to do more with a corrective exercise program.
Understandably, not everyone has access to a qualified manual therapist all the time, so you can always utilize self-myofascial release in the interim. Here, in a video from Show and Go: High Performance Training to Look, Feel, and Move Better, CP massage therapist Chris Howard goes over a quick and easy way to loosen up the pecs:
The second area where you really can't go wrong is incorporating thoracic spine mobilizations. The thoracic spine has direct interactions with the lumbar spine, rib cage, cervical spine, and scapulae; as a result, it has some very far-reaching effects. Unfortunately, most people are really stiff in this region - and that means they wind up with poor core and scapular stability, altered rib positioning (which impacts respiration), and cervical spine dysfunction. Fortunately, mobilizing this area can have some quick and profound benefits; I've seen shoulder internal rotation improve by as much as 20 degrees in a matter of 30 seconds simply by incorporating a basic thoracic spine mobility drill.
That said, not all thoracic spine mobility drills are created equal. Many of these drills require the glenohumeral joint to go into external rotation, abduction, and horizontal abduction in order to drive scapular posterior tilt/retraction and, in turn, thoracic spine extension and rotation. If you've got a cranky shoulder, this more extreme shoulder position usually isn't going to go over well. So, drills like the side-lying extension-rotation are likely out:
For most folks, a quadruped extension-rotation drill will be an appropriate regression:
And, if the hand position (behind the head) is still problematic for the shoulder, you can always simply put it on the opposite shoulder (in the above example, the right hand would be placed on the left shoulder) and keep the rest of the movement the same.
Last, but certainly not least, you can almost always work on forward head posture from the get-go with someone whose shoulder hurts. We start with standing chin tucks, and then progress to quadruped chin tucks.
Additionally, working on cervical rotation is extremely valuable, although teaching that is a bit beyond the scope of this post.
Keep in mind that these three broad initiatives are really just the tip of the iceberg when it comes to a comprehensive corrective exercise plan that would also include a focus on scapular stabilization and rotator cuff exercises, plus additional mobility drills. They are, however, safe entry-level strategies you can use with just about anyone to get the ball rolling without making a shoulder hurt worse in a strength and conditioning program.
For more information on what a comprehensive shoulder rehabilitation program and the concurrent strength and conditioning program should include, check out Optimal Shoulder Performance, a DVD set I co-created with Mike Reinold, the Head Athletic Trainer and Rehabilitation Coordinator of the Boston Red Sox.
The Optimal Shoulder Performance DVD is a phenomenal presentation of the variables surrounding shoulder health, function, and performance. It combines the most current research, real world application as well as the the instruction on how to implement its vast amount of material immediately. After just one viewing, I decided to employ some of the tactics and methods into our assessment and exercise protocols, and as a result, I feel that myself, my staff and my clients have benefited greatly.
Michael Ranfone BS, CSCS, LMT, ART
Owner, Ranfone Training Systems
If you've read much of my stuff, you've probably come to realize that I'm quite the shoulder geek. With that title comes a lot of questions at seminars and via email, and one of the more common ones is whether I think direct rotator cuff strengthening exercises are necessary for everyone. A lot of coaches say that they aren't essential, but I beg to differ for five reasons. Here's why:
1. Bad Posture - Nowadays, pretty much everyone has rounded shoulders - which means that the scapulae are winged out. When a shoulder blade isn't sitting right, the rotator cuff muscles that attach to that scapula are at a mechanical disadvantage because they are outside of their ideal length-tension relationship for creating force; it's analogous to trying to shoot a cannon from a canoe.
Incorporating some direct rotator cuff exercises not only strengthens muscles that you know will be operating at a mechanical disadvantage, but also educates a lifter about how the scapula should be positioned for ideal shoulder function.
2. Shoulder impingement is a physiological norm. - Research from Flatow et al. demonstrated that everyone – regardless of age, activity level, sport of choice, acromion type, gender, you name it – has direct impingement on their rotator cuff tendons. If you know a region is going to get beaten up regardless of what you do in your life, why wouldn't you opt to strengthen it proactively?
3. Rotator cuff tears are far more common than you think. - In consideration of the previous point, it should be no surprise that rotator cuff tears are actually far more common than one might realize - even if you look at asymptomatic subjects. Connor et al.discovered that on MRI, 40% of asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears. The general population is no different; Sher et al. took MRIs of 96 asymptomatic subjects, finding rotator cuff tears in 34% of cases, and 54% of those older than 60. And these studies don't even include the ones who are actually in pain! It makes sense to strengthen these areas proactively - even if your shoulder doesn't hurt...yet.
4. Lots of people also have labral tears. - In the past, I've written quite a bit about Active vs. Passive Restraints. In the shoulder, the rotator cuff would be considered an active restraint, as it's something that can be strengthened to improve dynamic stability. The labrum, on the other hand, doesn't get stronger with exercise; it's a passive restraint that provides stability. So, if the labrum is torn or frayed (as it very commonly is in both lifters and overhead throwing athletes), then the active restraints - the rotator cuff tendons - need to pick up the slack.
5. The "Just do normal stuff and the rotator cuff will take care of itself" philosophy isn't working. - That's been tried for quite some time, and nowadays, as a society, we move like absolute crap and - as noted above - have a boatload of issues on MRI even if we're asymptomatic. With respect to the cuff, we've built the deltoids up to the point that they absolutely overwhelm the rotator cuff (particularly the supraspinatus), which is trying to prevent the humeral head from migrating upward into the acromion.
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!
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!
I made an effort to get more videos up on the site this year, as I know a lot of folks are visual learners and/or just enjoy being able to listen to a blog, as opposed to reading it. Here are some highlights from the past year:
The Absolute Speed to Absolute Strength Continuum - Regardless of your sport, there are valuable take-home messages. I just used throwing velocity in baseball pitchers as an example, as it's my frame of reference.
Should Pitchers Overhead Press? - This was an excerpt from Mike Reinold and my Optimal Shoulder Performance seminar (which became a popular DVD set for the year).
Shoulder Impingement vs. Rotator Cuff Tears - Speaking of Mike, here's a bit from the man himself from that seminar DVD set.
Thoracic and Glenohumeral Joint Mobility Drills - The folks at Men's Health tracked me down in the lobby at Perform Better in Providence and asked if I could take them through a few shoulder mobility drills we commonly use - and this was the result.
Cressey West - This kicks off the funny videos from the past year. A few pro baseball players that I program for in a distance-based format created this spoof video as a way of saying thank you.
Tank Nap - My puppy taking a nap in a provocative position. What's more cute?
Matt Blake Draft Tracker - CP's resident court jester and pitching instructor airs his frustrations on draft day.
1RM Cable Horizontal Abduction - More from the man, the myth, the legend.
You can find a lot more videos on my YouTube page HERE and the Cressey Performance YouTube page HERE.
A New Paradigm for Performance Testing - This two-part feature was actually an interview with Bioletic founder, Dr. Rick Cohen. In it, we discuss the importance of testing athletes for deficiencies and strategically correcting them. We've begun to use Bioletics more and more with our athletes, and I highly recommend their thorough and forward thinking services.
A New Paradigm for Performance Testing: Part 1A New Paradigm for Performance Testing: Part 2
I already have a few series planned for 2011, so keep an eye out for them! In the meantime, we have two more "Best of 2010" features in store before Friday at midnight.
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Today, we move forward with more strategies for correcting bad posture. In case you missed it, be sure to check out Strategies for Correcting Bad Posture: Part 1. We pick up with tip #5...
5. Don't overlook a lack of glenohumeral (shoulder) joint internal rotation. When it comes to bad posture, everyone thinks that the glenohumeral joint is only a "player" when it's stuck in internal rotation; that is, the ball - or humeral head - is rotated too far forward on the socket - or glenoid fossa - meaning that the individual just doesn't have adequate external rotation. And, this is often true - especially in non-athletic populations.
However, you'll also very commonly see poor posture folks who present with big glenohumeral internal rotation deficits (GIRD), particularly on the right side (for very legitimate reasons that go well beyond the scope of this article). This is much more common in athletes, particularly overhead throwers (read more: Static Posture Assessment Mistakes). When the posterior rotator cuff is stiff/short and there is an internal rotation deficit, we have to substitute excessive scapular protraction (winging) or thoracic flexion/rotation each time we reach for something.
So, for many folks, posterior shoulder mobility and soft tissue work is an important inclusion in cleaning things up in terms of appearance, function, and shoulder health. If - and only if - you've been assessed and it's been determined that you have an internal rotation deficit that compromises your total motion at the glenohumeral joint, you can integrate some gentle sleeper stretches (scapula stabilized!) to get a bit more ROM in the posterior cuff.
6. Don't overlook a lack of glenohumeral (shoulder) joint flexion. The shoulder is a tremendously mobile joint, so we need to appreciate what goes on outside the transverse plane as well. In particular, I see shoulder flexion limitations as a big problem. These limitations may come from the lat, teres major, long head of the triceps, or inferior capsule. Another overlooked cause can be posterior cuff restrictions; it's not uncommon to see both GIRD and major shoulder flexion limitations on the same side. As the picture below shows, the infraspinatus and teres minor run almost vertically when the arm is abducted a mere 90 degrees - which means that they're struggling to lengthen fully to allow full shoulder flexion (and abduction, for that matter).
These restrictions that can contribute to both faulty compensation patterns in certain positions, as well as overall bad posture chronically. Let's have a look at what these issues look like in the real world. First, in someone with a shoulder flexion limitation, you'd first want to check them in the supine position, with the knees flexed and back flat (to avoid substituting lumbar extension for shoulder flexion). Ideally, the arms should rest flat on the table - so this would be a "not-so-hot" result (especially since the arms "fall" to the sides a bit instead of staying in "attempted flexion"):
Next, let's take this same shoulder flexion limitation, and look at what would happen actively. In the first three reps of the video below, take note of the position of our subject's head at the start and finish of each rep; you'll see that as he "runs out" of shoulder flexion, he substitutes forward head posture. On the next three reps, after I cue him to keep his cervical spine in a more neutral posture, he has to arch his back excessively (lumbar hyperextension) to complete the movement.
Now, imagine taking this walking disaster (only kidding; I had Dave fake it for the video, as he's actually a finely tuned trained killing machine who can't be stopped by conventional weapons - and he's single, ladies) taking up overhead pressing, Olympic lifting, or just reaching for a glass on the top shelf. Then, imagine him doing those tasks over and over again. Obviously, the posture will get worse as he reinforces these compensation schemes - but something is going to surely break down along the way; it's just a question of whether it's his low back, shoulder, or neck!
Correcting these issues is easier said than done; as I noted, there are several structures that could be the limiting factor. However, for those looking for a relatively universal stretch they can use to get a bit of everything, I like the wall lat stretch with stabilization, one piece of a comprehensive (but not excessive and boring) static stretching program included in Show and Go.
7. Don't ignore the thoracic spine. The previous two examples focused exclusively on the glenohumeral joint, but the truth is that it is tremendously dependent on thoracic spine positioning. Ask any physical therapist, and they'll tell you that if they can get the thoracic spine moving, they can instantly improve glenohumeral joint range-of-motion without even touching the shoulder (this is incredibly valuable with folks who may have stiff glenohumeral joints that can't be mobilized aggressively following shoulder surgery; they need ROM in any way possible). And, truthfully, you can substitute a lack of thoracic spine extension for the shoulder flexion problems and compensation schemes above, and a lack of thoracic spine rotation can work in much the same way as a GIRD (substitute excessive scapular protraction with reaching tasks).
If you ever want to quickly check to see what limiting thoracic extension does to someone's upper body posture, just put them in supine position and push the sternum/rib cage down - which will bring the thoracic spine into flexion. Watch what happens to the position of his chin, and the size of the "gap" between his neck and the table:
Now, just consider what kind of "yank" this puts on the sternocleidomastoid chronically...
...and you'll understand why a lack of thoracic spine mobility can give people enough neck pain and tension headaches to make Lindsay Lohan's hangovers look like a walk in the park. And this doesn't even consider what's going on with scalenes, suboccipitals, levator scapulae, subclavius, and a host of other muscles that are royally pissed off! Also, think about all those folks in your gym doing hours and hours of crunches (especially while tugging on the neck). Ouch.
For that reason, we need to get our thoracic spine moving - and more specifically, we need to get it moving in both extension and rotation. I've mentioned in the past that the side-lying extension-rotation is one of my favorites (assuming no symptoms); remember that the overwhelming majority of the range-of-motion is coming from the upper back, not just the shoulder:
Here's another we're using quite a bit nowadays in our folks who have good internal rotation (which we want to keep!):
8. Watch your daily habits and get up more frequently. I'm at 1,140 words for this post right now - plus several pictures and videos. In other words, some of you might have been hunched over your computer screens trying to figure out what I'm saying for over 20 minutes now - and that's when "creep" starts to set in an postural changes become more and more harmful (both aesthetically and functionally).
With that in mind, make a point of getting up more frequently throughout the day if you have to be sitting a ton. Likewise, "shuffle" or "fidget" in your chair; as Dr. Stuart McGill once said, "The best posture is the one that is constantly changing." Now, shouldn't you get up and walk around for a few minutes?